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QUIN <br /> P D SAN.PJOAQUIN Environmental Health Department <br /> aill `I —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;.com feted b APPLICANT <br /> Business Name Lic. Plate# 3 ;2)tob6`I L1F <br /> Owner/Operator Name �. /�i1tY� D2 v�l-"w— <br /> Business Mailing Address 'A': / p`29c2_ <br /> Cittqy"I G�n -StateMZip S'V5_ us. Ph A Pf-�1/ `1997AIt. Ph. <br /> [,G� <br /> I, J�tlt"H AWik Awd"ko,? Ce ;ela , 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 i ft <br /> continued,t e permit holder must not the EHD. Failure to notify this office may result in permit <br /> revocation nd pe alt! <br /> Signature Date 1./¢ ''2-- <br /> 2. To be com feted bv COMMISSARY OWNER/OPERATOR <br /> r <br /> Commissary Name � FA# <br /> Address &1 L?• Bus. Pho(ne ef� 7� <br /> City ` ttic= Zip !c (_ wner/Operator ,Q �r 7if2l <br /> Check all appropriate services provided: <br /> p Wastewater disposal 115-3-compartment sink d Electrical hook-ups <br /> g(Solid waste disposal E3 Food preparation Toilet and handwashing <br /> ff Hot& Cold water for cleaning 0 Store refrigerated food Potable water <br /> O S <br /> t dry food/s p les / �Overnight parking 16 Vehicle wash <br /> I,, V/A A1Vj*1Vu& , hereby state that the information I have provided is current, true and <br /> correct to theb of my knowledge,;andthe California Health &Safety Code requirements. If the food facility <br /> operator fails mply with the cothis agreement, or if this agreement is modified or cancelled, the <br /> commissa w shall notify theately. <br /> Signature Date �a- <br /> 3. To be com feted 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />