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SAKJOAQUIN Environmental Health Department <br />` —COUNTY-- <br />reom ss here, <br />grows <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 />1 / <br />Business Name fDuZ : ` V Lic. Plate # C2 2 &1 <br />Owner/Operator Name <br />9 <br />Business Mailing Address l <br />City4eipgsa 1LSus. Ph. It. Ph. <br />I, O hereby state that the above information is current, true and correct to <br />the est of my knowledge and agrke to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin C unty 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 pepities, <br />Signature - Date t/ Q leg <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name P i C V, r✓ G ca;=9r✓7 FA# <br />Address 2L415,t= min/=C! AV r- Bus. Phone a a– C1uk4-1-7LAE1 <br />City Y7D Gk TON Zip CA G1 Sao r Owr>�Operator OW ni F n (n <br />Check all appropriate services provided: Q A <br />N <br />la Wastewater disposal 0 3 -compartment sink electrical hook-ups ; <br />m <br />G <br />® Solid waste disposal 0 Food preparation 5,'roilet and handwashing p 3C <br />® Hot & Cold water for cleaning V�Store refrigerated food 13 Potable water - m <br />R Store dry food/supplies WOvernight parking 0 Vehicle wash > ; n <br />C <br />I, hereby state that the information I have provided is current, true and <br />rr <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facilityMN <br />' <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the (CT <br />3 <br />commissary owner shall notify the EHD immediately. <br />Signature J_�,, �� %r Date �-3- <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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />S <br />