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SAN JOAQUIN Environmental Health Department <br /> — <br /> —COUNTY--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility e, Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name Lic. Plate# '-IS Z 2 3S <br /> Owner/Operator Name <br /> Business Mailing Address .2 �J q P7&fVT1('t LL0 <br /> City—2CKPId State L11 Zip .j2- a Bus. PI S Y� Z �/�-6y�/ Alt. Ph. <br /> I, .50u6,9NH JOHN 5V-S,+V , hereby state that the above information iscurrent,true and correct to <br /> the best of my knowledge and agree of utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the udder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date 5 /Z r <br /> 2. To be com'pieQd by COMMISSARY OWNER/OPERATOR <br /> Commissary Name �04) Cd7''Jc/iAL tuC� C Q1j(ck FA# <br /> Address / 7/ 71 o ld(eNJ .5-T Bus. Phone�ZO`I) -Z '(5 - ✓-V 6 <br /> CityS I «'T ti G<f Zip �%U C Owner/Operator fl R 1 ��DC <br /> Check all appropriate services provided/:: <br /> 3 � 1 <br /> ,. Wastewater disposal 0 -compartment sink 11 EElectrical hook-ups <br /> �g//Solid waste disposal Food preparation 0�Toilet and handwashing <br /> _ HHot&Cold water for cleaning Store refrigerated food �dPotable water <br /> hG StL3oree dry food/supplies _Overnight parking 0/Vehicle wash <br /> AI, / :�Z-R/ 4 6 hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner sh II not tha -iD'i ediately. <br /> Signature Datej / 6 12- <br /> 13. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 vsnrw.sjgov.org/ehd <br />