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?Rory -4340 <br /> SAN JOAQUIN EnviriaonmenW Heafth Department <br /> - --C Q U rNl T Y----- <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 leted by APPLICANT <br /> Business Name k� C_C.✓w�6)1 Lic. Plate# <br /> Owner/Operator Name 4!rY?o c `o Ll H`�7 0 1 <br /> Business Mailing Address I A j l F > /.- L r 7 <br /> City T Y,-, State (�.il Zip It 5 Bus. Ph. 10 q'T2 it. Ph. <br /> M6,40� , hereby state that the above information is current, true and correct to <br /> the es�knowleb'ge 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 G ; Date <br /> 2. To be Completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name r`'��i ern ra CraL' v-r� 5 Q�Q4211 FA# <br /> Address ' `/ 71 Q S. A,r-I , r Ir- C"' Z Bus. Phone <br /> City Owner/Operator <br /> Check all appropriate services provided: <br /> &ANastewater disposal 10<13-compartment sink II'Electrical hook-ups <br /> V <br /> iolid waste disposal 9 Food preparation Toilet and handwashing <br /> ot& Cold water for cleaning 'Store refrigerated food Potable water <br /> i=3 Store dry food/supplies Y20vernight parking MUT"ehicle wash <br /> I, �fLnz-oz, 12"bLo 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 /> Signaturef"S L Date �� 2 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 wvvw.sjgov.org/ehd c <br /> v <br />