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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-1)yAPPLICIANT <br /> Business Name <1V\ d2 1 Z Lic. Plate# 3tQ.S`S��D <br /> Owner/Operator Name 1-A`I 1k of y Nt rodt�n <br /> Business Mailing Address 505 esovxeer r. r, et 54 <br /> City I State</Q Zip%2H v Bus. Ph. Alt. Ph. <br /> I, [A" V� a [ j If tL�" , 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 an rIties. <br /> Signature Date I a -a - a611 <br /> be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name tt-ae�;LA' -041m, 5FA# <br /> Address UZ/e S .54ccr-tion-+, _4 Bus. Phone 62o-Q ZLr-1– 93 <br /> City ,_-) n/ Zip q YZ 9c Owner/Operator �ed'a'atra Dchu� <br /> Check all appropriate services provideed:� � � <br /> �stewater disposal /compartment sink Electrical hook-ups <br /> /Solid waste disposal tl�v Food preparation �ilet and handwashing <br /> V/'HHot & Cold water for cleaning ur5tore refrigerated food CWotable water <br /> 6 Store dry food/supplies 113'6�vernight parking El-V`6'hicle wash <br /> I, �G�•�hl i SJ c!1 AZ-)�rC&. , 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. y <br /> Signature Date I I <br /> 3. To be completed-11111W, V 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 />