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SAN4JOAQUIN Environmental Health Department <br /> T —COUNTY— <br /> __ <br /> 'QUrod/ <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 /> l ,be completed by APPt;, ANT <br /> Business Name 065 �ICe�i '(/lP;l s Lic.Plate# <br /> Owner/Operator Name A41ee, V4� eQ- (4�� <br /> Business M �r' <br /> Mailing Address -0617 �76AW <br /> City llT"J00 State M-ZipBus. Ph. �494*74-,?9>7JAlt. Ph. <br /> I. 31AIM, J)&VRA-/I�an ,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 /> pry <br /> Signature 7�/hdds. Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address ZO(o f Akl%l/r a•y A(LIC,.oay X101 Bus. Phone 2M-7S& 4(49? -7 <br /> city72,oc�� Zip 9 SAO L( Owner/Operator 14C/L1 <br /> Check all appropriate services provided: <br /> El-Wastewater disposal d3-compartment sink 0�Electrical hook-ups <br /> 0 Solid waste disposal [;rFood preparationToilet and handwashing <br /> 0 Hot & Cold water for cleaning 6 Store refrigerated food Q/Potable water <br /> Id Store dry food/supplies 0 Overnight parking O Vehicle wash <br /> I, '7>SW 1 iS rA ti V'L— , hereby slate that the information I have provided Is current,true and <br /> correct to the best of my knowledge,and meets the Califomia 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 t� Date /-3CJ-2o2-?— <br /> be <br /> o2-Zbe 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 />