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SAN�JOAQUIN Department <br /> Environmental Health De <br /> —COUNTY— <br /> Greatness grows here. <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 Name V 0:tx3' ,� ���� u°: Lic. Plate# Z z gy3 <br /> Owner/Operator Name Ft�::Q\oz :acc) f1��pn r vGt�vyt <br /> Business Mailing Address - <br /> Cityy,,,u.niylt CaW State 4-zip RSZ31 Bus. Ph. ,�Zjo 3�S-z3zo 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 Ooldef must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. l <br /> Signature jjt; Date 1 Z 2T Z <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name <br /> am��e (ln�1-�1»tom. ZA-e- In S�PPI�FA# <br /> r <br /> Address fZ VQ S, Airaj/4- A Bus. Phone 2C,!�j —T V46 <br /> City r144oA zip G1 V,&6 Owner/Operator 2 ,, 1-�U!:> <br /> Check all appropriate services provided:: <br /> El/Wastewater disposal 112/3-compartment sink [17' Electrical hook-ups <br /> M/Solid waste;disposal d Food preparation CJ/Toilet and handwashing <br /> Cl/Hot & Cold water for cleaning ll Store refrigerated food EYPotable water <br /> [Store dry food/supplies Ml/Overnight parking Q'Vehicle 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. t� <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />