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SAN J Q A Q U { N Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility i� 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 b APPLICANT <br /> Business Name/7CO,5 6-& I// <br /> � Lic. Plate# gJr.,7 6j-y,2- <br /> Owner/Operator Name tI P fyl A M>Q 0 CASTi 1- t-o R AIM!QRZ <br /> Business Mailing Address 133 5 Lit 2kDL R 1/ <br /> CitynJr - �/i1 StateeCA Zip O( 6 Bus. Ph. I Alt. Ph. <br /> I, #C/74 94Q 'US 7-11-1-6) 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_Y/I"yW,Lf� 2o_S ," / Date Z G Z 2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name /&Q/() C�T�� IQuCk /FA# <br /> Address/7/7-5c. MAI O N 1T _Bus. Phone 4� -��u2� <br /> City_SO(1 -rp214 GI Zip 9.�Z U W Owner/Operator �I( T /(OC)}b C� <br /> Check all appropriate services provided: <br /> Wastewater disposal 0/3-compartment sink I"B Electrical hook-ups <br /> Solid wast!✓ disposal Food preparation Toilet and handwashing <br /> !/Hot&Cold water for cleaning UeStStore refrigerated food J-413otable water <br /> ,11'Store 9dry foo lies W Overnight parking R- Vehicle wash <br /> I, ! /i E /M.// a ,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 Come requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agrent is modified or cancelled, the <br /> commissary owner shaOoti the EHD it ediately.. <br /> Signature Date o2 / /Z)Z Z <br /> 3. To be com leted 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 wvvw.sjgov.org/ehd <br />