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SAN JOAUN EnvirroirimenW Heafth Department <br /> COUNTY--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Comp/efe 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 /> Business Name 12Ci 170cl 6 1"1 tf-.+.��•�i�r ` Lic. Plate# u CIS;: <br /> Owner/Operator Name_4�,, �A <br /> Business Mailing Address _( ( nn /\•�� <br /> I � <br /> City i c �LjC n State�Zip Bus. Ph.Vl6 P�(?d?a C: Alt. Ph. <br /> 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 <br /> 2. To be completed by COMMISSARY OWNIER/OPERATOR <br /> Commissary Name �� i'��V FA# <br /> Address %,% -r'Y -q+ i Bus. Phone lZ6'1) 7 741 SS`53`11 <br /> City L",��' _Zip J ZE✓d Owner/Operator Lid I <br /> Check all appropriate services provided: <br /> ErGVastewater disposal compartment sink 0- ectrical hook-ups <br /> olid wash disposal #Food preparation toilet and handwashing <br /> mot &Cola) water for cleaning ore refrigerated food E-5otable water <br /> amore dry food/supplies M-6vernight parking r� Vehicle wash <br /> I, A7 'r-,',`e, , 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 Z ' "7 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.sigov.org/ehd <br /> V <br />