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SAN JOAQUIN Environmental Health Department <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 Name tlk �vCA If— �t zol}63 <br /> Lic.Plate# <br /> Owner/Operator Name va u=-u <br /> Business Mailing Address Z?QCA k <br /> City l.lnde5lo State LA Zip gs3s1? Bus. Ph. Aft. Ph._� <br /> 1, 1 Ui' t a�� ,hereby state that the above information is current,true and correct to <br /> the 40st of rrif knowledgd 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 discontin d,th permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penald <br /> Signature Date OIpq I zo T-1 <br /> 2. To be completed by COMMISSAR,�IY�, OWNER/OPERATOR <br /> Commissary Name iSa�"k /%DdG5><0 FA# -- <br /> Address /,211 S. S✓,i� Bus. Phone�.?D?)33T- 3663 <br /> City_A Zip 9.53-6 Owner/Operator (X2/41 J�V?t <br /> Check all appropriate services provided: <br /> Wastewater disposal 13'3compartment sink 12Electrical hook-ups <br /> UAS�Clid waste disposal [2 Food preparation 11-Toilet and handwashing <br /> U'Hot & Cold water for cleaning [;KStofe refrigerated food la-Potable water <br /> 0 Store dry food/supplies ff�Overnight parking vehicle wash <br /> mdek W f-L✓✓2-- , 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 <br /> DateA- 9-a 1 <br /> be com leted b the ENV HEALTH unsd` aj,:: �dafSa JAa.,` <br /> 51��1sfaus Ca�wT�n�olin um <br /> is located in �—ty he bove The above food <br /> The commissary checked services are facility meets the <br /> Commissarc <br /> commissary <br /> requirements in California Health & Safe Code. T <br /> Please notify EHD if the status of their operating permit changes. available at the <br /> above commissary q } <br /> Date <br /> REHS Signature <br /> 1868E Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 <br /> www.sjgov.org/ehd <br />