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SA N' J 0 A Q U I N Environmental Health Department <br /> --COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1To be corn leted,ti APPLICQN7� ,. ` ;: I �� . `. <br /> Business Name t (L naf:, -ro-uo—) )r-ucX Lie.Plate# <br /> Owner/Operator Name N1,(* :Toy j_'TrU/ lac) <br /> Business Mailing Address t 'i. ,r <br /> c;ty�Stat`e C Zi F, ( Bus. Ph. 7 6 L -5TO"HUb lt. Ph.7 Oa- b LO `-w-00(p <br /> hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to Otilize 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 permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Sig nature Date I Z <br /> 2. To le._com leted b COMMISSARY,OWNER7,QPERATOR <br /> Commissary Name 4''1 a,I r' ''1' >' �a z t��Gn FA/# <br /> AddresBus. Phone <br /> City Lc Qi _Zip 7 YG'Owner/Operator <br /> Check all appropriate services provided: � <br /> lastewater disposal 0--S-'compartment sink M' lectdcal hook-ups <br /> -8olid waste disposal13-food preparation E3oilet and handwashing <br /> ER'-4ot& Cold water for cleaning More refrigerated food }table water <br /> i�-Store dry food/supplies Q6 6vemight parking LY ehicle wash <br /> I �C Ya, 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 shall notify the EHD immediately. <br /> Signature � Date Cc <br /> 3 ,To.be eom Leted b `the ENVY:HEAL'TH''urlsdiction outside of-San iloa-. uln Go:; <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 www.sjgov.org/ehd <br />