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NGVIN-.. <br /> SANsJOAQUIN Environmental Health Department <br /> j- —COUNTY— <br /> �9r5' Greotness grows her?. <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 /> Business NameLic. Plate# <br /> Owner/Operator Nameg& U,5 121e ,4119NIU <br /> Business Mailing Address f' 6 3b303 3 <br /> City,{ State 6A Zip .,. 24 � <br /> 3 Bus. Ph b ✓3-Alt. Ph. <br /> I, WA A[ U5 14q6- 1!/E , 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 � / �V Date a` Z 0 Z Z <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UAP010 MOX16hT (t(k 06 FA# <br /> Address 1717s , uoJtolL) ST Bus. Phone 1©�%Z 6 <br /> City-5kc(r8 (6, -h zip K106 Owner/Operator dRE / (Xfid l7 <br /> Check all appropriate services provided: <br /> Wastewater disposal (j °-compartment sink 0 Electrical hook-ups <br /> Solid waste disposal O Food preparation �T ilet and handwashing <br /> 0 Hot & Cold water for cleaning 0 Store refrigerated food (� table water <br /> 0 Store dry food/supplies 0 Overnight parking �Vehicle wash <br /> I, �ae (] 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 owners II notify the EHD 'mmediately. <br /> Signature Date 2 /-2, 1,26 2—'2_ <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 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />