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P SAN JOAQUIN Environmental Health Department <br /> " Wh1i —COUNTY-- <br /> Greatness gro::c 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/ <br /> Business Name 5`GkS�4J t h, ajoY Lic.Plate# <br /> Owner/Operator Name %j4A4 W&. J Pw/l i-P-5 <br /> Business Mailing Address G 71419 <br /> Aol slJi ale <br /> Cit y�i�_StateG/Qzip151f'Bus. Ph. 2!0g'9d e'-"yA t. Ph. <br /> I, Sib+"JK' 06W t ll()?0 , 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 i0415rv"`� Date 7-2- 2-/ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name—a", S-0t_S' �FLlN M FA# <br /> Address 0 LoBus. Phon O <br /> CitykAj �A' 0'10 zip 9 Owner/Operator ^ a 4Q 14Nl�\ <br /> Check all appropriate services provided: <br /> I9 Wastewater disposal k 3-compartment sink ❑ Electrical hook-ups <br /> JR Solid waste disposal JW Food preparation WToilet and handwashing <br /> 4 Hot & Cold water for cleaning $ Store refrigerated food ePotable water <br /> Mr Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> I, 1 t p 'YN t �xr jy,<;�ArAck,(V k) ,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 owne s �ll notify�t mmediately. v� <br /> Signature jL Date l Z, <br /> 3. To be completed b . the ENV HEALTH jurisdiction outside of San Joa un 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 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />