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SAN JOANN Heafth hspaulmanutt <br /> -COUNTY---- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 9 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 A LF_Y?; P�'1 I C 1 �2\LL S Lic. Plate# 3 7 I� <br /> Owner/Operator Name ,'�O i�kl nAf, ) ('�7k;r-C i r,v �I0 C(-d ) <br /> Business Mailing <br /> ��Address Z-1 4 `moo ( rl._ 4 ave- �, <br /> City t✓Ai'Z'- <br /> L vl;, State C"',,Zip �! �� Bus. Ph. ;669 )�R - :Ph. <br /> I, 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 4A C-lar (C" CIL4Ct 01 �J ' Date / <br /> ' 1 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> �n1 - <br /> Commissary Name 1uQ0 $DrK !� !� trix� .��ipth FA# <br /> Address c 4.rcaorA, (A Bus. Phone <br /> City S �O CAbM Zip $ Owner/Operator �-e� 12uh d c� <br /> Check all appropriate services provided: <br /> ff�wastewater disposal 3-compartment sink DR/Electrical hook-ups <br /> Solid waste disposal Food preparation 26oilet and handwashing <br /> _d Hot& Cold water for cleaning r' Store refrigerated food r_ Potable water <br /> Store dry food/supplieslOvernight parking �/ehicle wash <br /> I, 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 <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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wvvw.sjgov.org/ehd <br />