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SANJOAQUIN Environmental Health Department <br /> i —COUNTY— <br /> . <br /> Greotness 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 U 0<�6, "tib , CuC S Lic. Plate# Z2, 893 <br /> Owner/Operator Name aco iW)ek,c va ✓yt <br /> Business Mailing Address F We,,tj4te - <br /> City�Wvcv�c�lt (a8,Q StatelLA-Zip gS7,31 Bus. Ph. Sre 3)-5-232o Alt. Ph. <br /> I, hU +l 1:V'3 A\\0 a,4 Y.., . v\ , 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 told gY must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. 1 <br /> Signature ,� ���- �� Date i Z Z.Z. <br /> 2. To be completed �baa COMMISSARY OWNER/OPERATOR <br /> (/C <br /> Commissary Name s�1-lb,fnt�. L�i✓ l to , SuO12FA# <br /> Address !7 Y Yc/ S, ko-Qa/-l- 1+ge .:4 Bus. Phone Z(>!�t - G/- I V46 <br /> City V1 Zip q 6 Owner/Operator �2z�a <br /> Check all appropriate services provided: V <br /> pZWastewater disposal 12/3-compartment sink Cil Electrical hook-ups <br /> Q/Solid waste disposal Ii Food preparation ED/Toilet and handwashing <br /> Q7 Hot & Cold water for cleaning E Store refrigerated food [YPotable water <br /> CCJI**'Store dry food/supplies 1Y/Overnight parking [31 Vehicle wash <br /> I, , hereby state that the information I have provided is current,true and <br /> correctto 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. p f <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 />