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SAN JOAQUIN Environmental Health Depart <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. To be completed by APPLICANT <br /> C� �c YI <br /> Business Name r; Lic.Plate# y3_` y766 <br /> Owner/Operator Name ACS ° !/qC'' O r-Cc <br /> Business Mailing Address 75%I .�/�G o /4-r :�Lc YO <br /> ' <br /> City(I 1 c Statd'�A- Zip 5.3 I Bus. Pttr,9lJ�Y.S0�7-15 Lam( Alt. Ph. <br /> ti <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 /> a 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 /> Signature Date <br /> 41ft2. <br /> To a com le COMMISSARY OWNER/OPERATOR <br /> Commissary Name '�Q FA# <br /> Address 12 If S -4` 54yvA Bus. Phone Later 3353'-366 3 <br /> City, Zip ! 135/ Owner/Operator �/d SAmer (r4b'w '-.r y <br /> Check all appropriate services provided: <br /> [� Wastewater disposal M 3-compartment sink W Electrical hook-ups <br /> 10 Solid waste disposal M Food preparation M Toilet and handwashing <br /> 10 Hot&Cold water for cleaning 10 Store refrigerated food 13 Potable water <br /> 13 Store dry food/supplies 0 Overnight parking 03 Vehicle wash <br /> I, Afark l,rs —Cry-6 ,hereby state that the information I have provided is current,true an. . <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 mLkDate �/zz /77 <br /> 3. To be 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 thl status of their operating permit changes. I '77 <br /> REHS Signature Date 3 �z3 ` Z 0ZL <br /> 1868 E.Hazelton Avenue I Stockton,Califomia 952051 T 209 466-34201 F 209 464-0138 1 www.sigov.org/ehd <br />