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SAN JOAQUIN Environmental Health Department <br /> —COUNTY-- <br /> Greatness grows here, <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ 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 q p <br /> Business Name ry \S X- TR6- 75 ReQ Lic. Plate <br /> Owner/Operator Name "fl_ V61?,Al ,rOA�&5 /t 4C,1J[//r/ <br /> Business Mailing Address F00_/, MOV/77 S101UAL 1s C!R <br /> CityS]C.I('�DS4 State(_ Zip 9Salo Bus. Ph.( ) 35/ -,Z7q,Z Alt. Ph. <br /> h1}/�l'r�J 114RG NL/Ii{ 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 OWNER/OPERATOR <br /> Commissary Name UN I O(l C-60-k//(IC T/'t dCk ✓�. N 6E2 FA# <br /> Address!7/7 ,5. d1/( ,IA/ ST Bus. Phone(2—! 2Q�� <br /> City 5%t7CkT�, C lk Zip 9�. .O�_ Owner/Operator �jRT //k1}61p <br /> Check all appropriate services provided: <br /> Wastewater disposal G'3-compartment sink Electrical hook-ups <br /> M-Solid waste disposal l Food preparation GR Toilet and handwashing <br /> 131'Hot& Cold water for cleaning (9'Store refrigerated food 13-Potable water <br /> S/to�rre dry food/supplies Clvemight parking drVehicle wash <br /> I,- L7s't E 7/I I fik , 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 EHIDD immediately. o <br /> Signature z —Date 0�(/a <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />