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SAN JOAQUIN Environmental Health Department <br /> - COU N" <br /> S'4MS, 3,1© <br /> COMMISSARY AGREEMENT <br /> _ o <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 <br /> Business Name '-i 1":ll '' 1✓k Ct NIC Lic. Plate# <br /> Owner/Operator Name K 1rt- a was(� a <br /> Business Mailing Address 22//���j �)dC�Sul V PUS etc <br /> City \�� �Glf1 State ZipvFS�(07 Bus. Ph.?-Oq q l -2�R Alt. Ph. <br /> NCA L&Qln[ZF S —, 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 anq penalties. _ t <br /> Signature Date q'� SO^ 2` <br /> 2. To be completed by-COMMISSARY OWNER/OPERATOR <br /> CommissaryName Za r—oMIJ4riG 1{otJes4-o FA# <br /> Address 12.1t 5. -V" SfrceP Bus. Phone Caoq) 338- 3 66 3 <br /> City AQ46k Zip 4535 t Owner/Operator C11d Scor Cgµ ':EEC' nc- <br /> Check all appropriate services provided: <br /> M Wastewater disposal Ift 3-compartment sink 13 Electrical hook-ups <br /> P Solid waste disposal (3 Food preparation ® Toilet and handwashing <br /> 0 Hot & Cold water for cleaning ® Store refrigerated food 0t Potable water <br /> ®' Store dry food/supplies M Overnight parking 91 Vehicle wash <br /> I, luL✓ 'S- , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, and meets the Californiad-lealth&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 Q�3o/z! <br /> 3. To be completed by th ENV HEALTH 'urisdiction outside of San Joaquin Co. <br /> The commissary is located in I j 1, (A�& County. The above food facility meets the <br /> commissary requirements in Califo nia Health & Safety Code. TA above checked services are available at the <br /> above commissary. Please notify HD if the status of their operating permit changes. <br /> 4 <br /> REHS Signatur Date <br /> 1868 E. Hazel n venue I Stockton, Lia is 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />