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SAN ,)OAQ U I N Environmental Health Department <br /> —COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 corn leted-by APPLICANT <br /> Business Name �_X_, �C{�l Lia Plate# /��/ f <br /> Owner/Operator Name 4 C <br /> Business Mailing Address , <br /> City'� State(!-#F Zip 9sa03 Bus. Ph�- �W -3yiy Alt. Pn.s a2 W7 <br /> I, 4 r)G� 2 ✓I I/ e hereby state that the above information is current,-true and correct to <br /> the best of my knowledge and agree to 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 permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties <br /> Signature /{/ Date / <br /> 2.To be completed by COMMISSARY OWNEWPERATOR -- <br /> Commissary Name L. A CQ (Y�P.c c FA# <br /> Address a0100 'L Bus. Phone `a0C1 /L16&1 <br /> City �UC�KEc� Zip gS205 Owner/Operator A <br /> C�: (J fne --t <br /> Chec all appropriate services provided: <br /> 2115astewater disposal Z-compartment sink E 'cal hook-ups <br /> ��}�olid waste disposal 0 Food preparation ; let and handwashing <br /> Ili Hot&Cold water for cleaning M St refrigerated food I�P ble water <br /> 13 r dry food pp iesvemight parking IrVehicle wash <br /> hereby state that the information I have provided is current We and <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails omp with the conditions of this greement, or if this agreement is modified or cancelled, the <br /> commissa weer s I notify the Eyjlimraedi^ ` <br /> Signatur ` Date e/ — A7"a7 <br /> 3. Tobe completed by the ENV HEALTH jurisdiction outside of San Joa_ tun 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 209 468-34201 F 209 464-0138 1 www.sjgov_orglehd <br />