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SANIOAQUIN Environmental Health Department <br /> —COUNTYj. <br /> — <br /> ..: <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections f and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To WCOM feted.by APPLICANT . J <br /> Business Name Gid lam/ Lic.Plate# 01W �1/ <br /> Owner/Operator Name <br /> Business Majing Address t Ci4Wt "t Zip D o0 – Bus. Ph.aZ 4� �j/O�o27D1Ait Ph. <br /> 1, 4a4elshereby 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 he permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date <br /> 2.To be completed-by COMMISSMY-OWNERIOPERATOR <br /> Commissary Name L f1 Cn MP.K:Cc r.k FA# <br /> Address 9Lg00 E �rNrA.VkayaM Bus. Phone \\a0r - 4.1 (-1 '�V 5 7� <br /> City GJ FU L►Klc�n Zip q5 Zo5 Owner/Operator <br /> Check all appropriate services provided:: <br /> Wastewater disposal "3 compartment sink :�Eli�'Gal hook-ups <br /> olid waste disposal L2 Food preparation T -let and handwashing <br /> Hot& Cold water for cleaning ® Stolerefrigerated food Pble water <br /> e dry food/ plies Overnight parking Vehide wash <br /> IQ/I�f��uC Z hereby state that the information I have provided is current,true and <br /> correct to the my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator tai o comply with the con Hons of this agreement, or if this agreement is modified or cancelled, the <br /> commissa owne hall imme - <br /> Signature ��Lc ', Date AJ —3o �� <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of Sar 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 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov_orglehd <br />