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P�1��o�oU ��1���1 He���l I��F©�rta ��t <br /> SANJOAQUIN A <br /> st —COUNTY— <br /> '�,,,-a;�`s' iaraatnea; grows Ler-. <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 RPj Hos 75*,r rivvv, - Lic. Plate#_ Mq q_13 <br /> Owner/Operator Name I ia <br /> LLL <br /> Business Mailing Address S-5 F Al pivw� Jr+ <br /> City S Huyl StateCA-Zip Bus. Ph.I'923-777-5-3 X11 Alt. Ph. ',Dq-OV 70-6c7?7 <br /> I, ' SZ hereby state that the above information is current,true and correct to <br /> the best of my know)edge 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 perm' older must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penal ' I <br /> Signature Date Cal()`'t 1 2PQ'&- <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name W i r I 0 FA# t� r� <br /> Address � 9. 6 Garlic, Ave, Bus. Phone_ 2®q -qe ,G�� 823 <br /> City5foc'ybir) Zip 200 Owner/Operator <br /> Check all appropriate services provided: <br /> Lj Wastewater disposal R�3-compartment sink AN Electrical hook-ups <br /> 49- Solid waste;disposal 0 Food preparation A Toilet and handwashing <br /> Hot & Cold water for cleaning 49 Store refrigerated food M Potable water <br /> Ada Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> I, Ky" JNA ?L 0l') , hereby state that the informational 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 sha tify the EHD immediately. <br /> Signature Date 2- <br /> 2 <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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />