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SAN ) OA Q U I N Environmental Health Department <br /> —COUNTY— <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 com, feted by AP/PLICA/NT <br /> f <br /> Business Name lCc� "L 6 1 , 1p.t Lic. Plate# q3-5117&(5 <br /> Owner/Operator Name ��gus lgl2' p o A <br /> Business Mailing Address 76W .5/ear � <br /> e- 14tf 9c <br /> i' hid <br /> City l<e e Stat�k Zip 5� Bus. P17. 3$p 6S r<_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 /> Signature Date. ,3— <br /> 2. To6e compleleifbv COMMISSARY, OWNER/OPERATOR <br /> Commissary Name 4 �misari-a �es,(o FA# <br /> Address lag It S. 7 '' 54yv,-_L Bus. Phone 6?2Z) 3353'-366 3 <br /> City /t'to s Zip 95351 Owner/Operator ('o,/d (nr_ <br /> Check all appropriate services provided: <br /> a Wastewater disposal 0 3-compartment sink M Electrical hook-ups <br /> IN Solid waste disposal IN Food preparation 0 Toilet and handwashing <br /> W Hot & Cold water for cleaning 0 Store refrigerated food 1121 Potable water <br /> ;a Store dry food/supplies 0 Overnight parking 10 Vehicle wash <br /> i, i� r-k 4 v is —4f vmr& -, 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 94! Date <br /> 3. To be completed by the-ENV HEALTH jurisdiction 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 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 />