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SAN 10AQUIN Environmental Health Department <br /> —COUNTY— <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 Lc, �Q X 1�0 Lic. Plate# <br /> Owner/Operator Name �Gv�rcc�c n Cn 6-kc-V1 <br /> Business Mailing Address <br /> LIZ <br /> City �i State/�ZipS Bus. Ph.(' M) _14142 -- GY+ Alt. Ph. <br /> i.�� <br /> I, "- ! ynL _� , hereby state that the above information is current,true and correct to <br /> the best of m0nowledge 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 anden lbe <br /> Signature '// aN� l Date <br /> 2. To be completed by_C.OMMISSARY OWNER/OPERATOR <br /> Commissary Name A71rA ct orl,r, i FA# <br /> Address tr Z� Pit j Bus. Phone��j-) ZZC? <br /> City Zip 35Z/0 Owner/Operator A'rr1k"4 .jtke' <br /> Check all appropriate services provided: � <br /> �l/astewater disposal 93compartment sink C Electrical hook-ups <br /> 13/Solid waste disposal 13 Food preparation 1 Toilet and handwashing <br /> [riot& Cold water for cleaning Q]"Store refrigerated food 0/15otable water <br /> m"-Store dry food/supplies M-16vernight parking Q,,Vehicle wash <br /> I, 4 2l Fa , 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 /6 <br /> 3. To be completed b" 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 />