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SAN-dOAOUIN Environmental Health Department <br /> i._41 `' —COUNTY— <br /> `9 , , ,'•` Greatness grow: Fere. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility v% 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 11M 1UC kn )An(r-Cn �e. S Lic. Plate# h c <br /> Owner/Operator Name &e✓ia ro 1/j i lg vg Mor o� 2S <br /> Business Mailing Address 1?15 5 f'�aW es A\/e <br /> City Aoc-1<6-1 Statef&Zip 9 2 t5 Bus. Ph. Alt. Ph. <br /> I, , 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 holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signatur Date 7 ( t-(— Z2_ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 1 CIC Ct o c t- C t FA# <br /> Address3 G n'I ` ry - V L Bus. Phone <br /> City ST-6 CI5'7-on/' Zip c/4 cfS2-S- Owr{er/Operator O Weer D GVH 90 <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal 0 3-compartment sink ql Bectrical hook-ups <br /> 7igrrn . <br /> 0 Solid waste disposal 0 Food preparation GYroilet and handwashing ®a Q <br /> 0 Hot& Cold water for cleaning P-Store refrigerated food ❑ Potable water <br /> 0 Store dry food/supplies Cl- 6vernight parking ❑ Vehicle wash y <br /> m <br /> I, hereby state that the information I have provided is current, true and W b Xcorrect to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility N m m <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the N ' D <br /> commissary owner shall notify the EHD immediately. <br /> Signature _�?ir o,� �..� o ' Date <br /> 3 To be com feted 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 />