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rt ' <br /> SAN JOAQUIN EnvlranmenW Health Department <br /> --COU NTY---- <br /> �t <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 Htw rl QZ C 5 ( y,,z. Lic. Plate# 4 411©g), <br /> Owner/Operator Name Roo Ard)e Cv,z= V 1c A,cVc <br /> Business Mailing Address Zo b9 P14fe fz. l <br /> City Stateo=+ Zip 1;-to Bus. Ph.)t n 1i) 2}s_t 3 c 3 Alt. Ph. - 7,z-- s s 6 <br /> I, \Zo S--. C✓V I- 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 IC-IZ-ZeZ ( <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> c r± <br /> Commissary Name e e,11 po'r n / !in 9 5L4T FA# <br /> Address ?_ VU S. cvc Bus. Phone 2C>q-- -�- <br /> City �;4oc-4e-,+wl oG Owner/Operator_ Rg-�� 2L"-) Lo <br /> Check all appropriate services provided: <br /> — Wastewater disposal I $ compartment sink Electrical hook-ups <br /> NI/' Solid waste disposal '''333���"'333/ d preparation Er Toilet and handwashing <br /> E/Hot& Cold water for cleaning 'r /FooStore refrigerated food rd Potable water <br /> Store dry food/supplies Overnight parking LVVehicle wash <br /> 0 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 - Date O Z <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 /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />