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SAN JQAQU6N EnArranmenW Heafth Department <br /> ----COUNTY--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections f 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 HQI ra oZ c�'S c y,,-u Cc, r'1%� Lic. Plate# 4`�), <br /> Owner/Operator Name Rote Ad,I/rrn CV -, it �[( AVCWa�- <br /> Business Mailing Address ;ZOV71 P1 fie 72&j <br /> City Skz(.k � State=+ Zip �sZo Bus. Ph.l<n-1) t}s--3 o0 Alt. PhA- 2z - iss <br /> I, \Zo r,-, C✓/Z- 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 i 0- 1 Z-Zc2 l <br /> 2. To be com leted by COMMISSARY OWNER/OPERATOR <br /> It d <br /> Commissary Name CC;% 1 Pu'r n ty, 8' nn Gi 5L42piti FA# <br /> Address esNVLA S. AC(-62nd wL—�Bus. Phone—r— -'5-(. <br /> City c-IG+oA Zip !2 r36 Owner/Operator 2L`b t-0 <br /> Check all appropriate services provided: <br /> Wastewater disposal vp compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation Pr Toilet and handwashing <br /> 12(Hot& Cold water for cleaning /Store refrigerated food �Potable water <br /> a/Store dry food/supplies O Overnight parking --/Vehicle wash <br /> I, ewe S L?=V6er) 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 U 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 />