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SAN ,Q A Q U (N Environmental Health Department <br /> O v N,T y. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ;� Caterer <br /> Complete sections f 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 Namel n A 1-9Ao OA p p Lic. Plate# 7659139 <br /> {m <br /> Owner/Operator Name fi (�t-rtt P It TR,,i C t A H 1 DA LG 6 <br /> Business Mailing Address 27—S 96K Rc>LT OR, ��(G <br /> city,,! OCCk�Dtl1 State_CLZip` S 7 Bus. Ph(2! ) "Q?Zt Alt. Ph. <br /> I, Al A ►.l qiR P. H I DAA A G 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 pQnnalties. <br /> Signature0.R `f C� Q (� Gti` Date C t ( 2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L<MjOrt ( 7C/�i 14 (tCk 1%�T!0- FA# <br /> Address17 17�s_WALtbal Sr Bus. Phone k d '.� � 5r f6 <br /> Cite C'K j-44 � Zip g$.2D 6 Owner/Operator /4_fi 6-b <br /> Check all appropriate services provided: <br /> 01 Wastewater disposal ,d3-compartment sink Electrical hook-ups <br /> !!/Solid waste disposal rk Food preparation Toilet and handwashing <br /> id Hot& Cold water for cleaning Store refrigerated food /Potable water <br /> iP/Store dry food/�sueplies t.l:'Overnight parking :L/Vehicle wash <br /> ! <br /> !MIM a , 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 /> commissaryown�h��oteElrmediately. <br /> Signat <br /> Date <br /> 3. 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 /> 1863 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />