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SAN -J OAQ U I N Environmental Health Department <br />—COUNTY— <br />COMMISSARY <br />OUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility a Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin -County also complete section 3. <br />1. Tobe cpm leted'b APPLICANT` <br />Business <br />Owner/Operator <br />Business Mailing <br /># R& L21,,6-0 <br />Cit I <br />t C -State <br />-Zip q'�3 �i Bus. Ph.�2-A9) �qQ 5gOYAlt. Ph. <br />I, 1 hereby state that the above information is current, true and correct to <br />the est of my knowledge and reu 1 y approved commissary in accordance with California Health & <br />Safety Code, and San Joaqui ty E vi �a� ntal Health Department (EHD) requirements. If the use of the <br />commissary is discontinued a per 'a;ho�d?�us notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. o I I <br />Signature l( I i,Kb1 / Date <br />To be:comp1ekd,,by.q_QWSSARY OWNER/OPERATOR <br />Commissary Name_P I C K (=i (2 �/C c (- P, & A", FA# <br />Address 2 U I`i L ri r illAV`[= Bus. Phone `k- q-- 0u'-- I-) <br />L� <br />City S' 70 r r , g,l Zip_ (-,a or �% s7 Owner/Operator e; I-✓' r) <br />Check all appropriate services provided: <br />13 Wastewater disposal 0 3 -compartment sink 10-2lectrical hook-ups <br />0 Solid waste,disposal C Food preparation Wfoilet and handwashing <br />0 Hot & Cold .water for cleaning ZL-Store refrigerated food Ci Potable water <br />® Store dry food/supplies 101 -Overnight parking Q Vehicle wash <br />1, , 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 / - ' H - � <br />3.To.be cpm letedb, the ENV HEALTH `:ucisdicton 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 <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www,sjgov.org/ehd' <br />cn :9 <br />O"? <br />0 N Z <br />q <br />Z9C <br />0M� <br />DMR <br />to > <br />< R <br />oM <br />°1 3 <br />