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SAN.J0A0UIN Environmental Health Department <br />—COUNTY— <br />Greatness brows Here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility s 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 �) V1 i r, n LP. A vvA; fir,C Lic.Plate#it D) rs �j 3- <br />Owner/Operator Name M rn ryv. ca y� l© N_Ce- C L, '15 ct <br />Business Mailing Address 27 23 fSciSq, r <br />Cityu�r ( State Zip Q 53c ,Bus. Ph. Alt. Ph( I o) <br />1,f,l.r, r. n^,rA ,rP_C L.; _C,_' 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 />2. To be completed b COMMISSARY OWNER/OPERATOR <br />Commissary Name /i l:; , 1. - _ --i " r A/tr_ FA# <br />Address Bus. Phone/ Le'`c) <br />City a '- i�r zip 1,57-,7 Owner/Operator h. %r ;:;,.,t, l c• •- <br />Check all appropriate services provided <br />a-Wastewaterdisposal 0 3 compartment sink }=f Electrical hook-ups <br />Gt' Solid waste disposal Food preparation I3�oilet and handwashing <br />13 Hot & Cold water for cleaning 0 Store refrigerated food E3 P table water <br />M Store dry food/supplies P; Overnight parking Vehicle wash <br />I, 1/,- -, ,.o , <✓ i A ,�7 t a. . 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 1,111 Date 6,* 5 ` < - <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 <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 />