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SA6JOAQUIN Environmental Health Department <br /> " P § —COUNTY— <br /> Greocness 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 A & t?1*i, /2S S/i'lG.1DC, LGL Lic. Plate# <br /> Owner/Operator Name �vi,5 V ��✓ �vrrf`C� <br /> Business Mailing Address 4103/ 5. CGwpeN 14el /Zd <br /> City //QjeS) State fgZip�s$Bus. Ph.'Z G/3 <br /> dgLf,(6�L Alt. Ph. <br /> I, p— .4o & hereby state that the above information is current,true and correct to <br /> the best of my Aowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Jo� 'n County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is disrorf(inu , the per er must notify the EHD. Failure to notify this office may result in permit <br /> revocation andr4 <br /> Signature Date <br /> 2.to be p6mpleted by COMMISSARY OWNER/OPERATOR <br /> Co " sary Name tel COmixtf i G 14061e5+0 FA# <br /> Address 12.11 -5. 7}'' 5*m&* Bus. Phone 62o4)338-3"3 <br /> City MOe'r4o Zip 9535% Owner/Operator CO3ws�! e 6DI"M'rim <br /> y b <br /> Check all appropriate services provided: <br /> Wastewater disposal 01 3-compartment sink 13 Electrical hook-ups <br /> Pil Solid waste disposal Food preparation ® Toilet and handwashing <br /> 19 Hot & Cold water for cleaning 13 Store refrigerated food ® Potable water <br /> Store dry food/supplies 13 Overnight parking M Vehicle wash <br /> I, A&rk L v t s^cn'* 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 oywwjnn�/e''r shall notify the EHD immediately. <br /> Signature /�(Lr/Lfr'it!-� Date ' /2R'/22^ <br /> 3. To be com feted bv the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in CIA/ County. The above food facility meets the <br /> ' <br /> commissary requirements in C ornia Health & Sa ety Code. The above checked services are available at the <br /> above commissary. Please noti the s tus of their operating permit changes. <br /> REHS Signature Date 7 <br /> 1868 E. Hazelto enue i Stockton, California 5 I T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />