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SAN JOQQUiN Environmental Health Department <br /> --COUNTY— <br /> Greatness yrcw. 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 &/1 <br /> VJ <br /> Business Name j�n9a r l A VW, - I,Vr Lic. Plate# <br /> Owner/Operator Namerl"ewtm PAf_+_,AS <br /> Business Mailing Addresses f3m 'S (��t�ai++4 kn <br /> City CAV+A�q- State_AZip 953 Bus. Ph. (9M 4 z_Alt. Ph. Cq&5) �t <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 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name- Cant414, 4:zd1' PZ4&I_ FA# <br /> _� <br /> Address 4oZtJ 5 p&_,y4e, :f- Bus. Phone 609) -7_Z1'–?3 DI <br /> City Zip g5Z`b Owner/Operator plle r"✓tt_ O&W'f^� <br /> Check all appropriate services provided: <br /> p"Wastewater disposal 121"�3-compartment sink 0" Electrical hook-ups <br /> [3/Solid waste disposal O Food preparation Er'foilet and handwashing <br /> i of & Cold water for cleaning tore refrigerated food `�otable water <br /> Gd Store dry food/supplies Overnight parking t(r vehicle wash <br /> I, �or�rtvr r SS�J' A Z , 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 li / — Date 3 Z)– ZL <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 />