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7- <br /> 5A N.DJ QAO U I N Environmental Health Department <br /> --COUNTY <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 1 and 2. ff your`commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be corn leted by APPLICANT <br /> Business Name �� �� Lic. Plate#_ raj_qq®_ <br /> Owner/Operator Name �ej-{ "Ppj Irc4 z-y, , <br /> Business Mailing Address V) . 5� <br /> City LOO 1 StateGP- Zip dd!,L-t Bus. Ph,VA--VO--35W Alt. Pty. <br /> 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. fff <br /> Signature Date 1 1 'Z, 1�, <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ° L �4 Ai <br /> FA# <br /> Address SS6er6Vr1PrL, S Bus. Phone r <br /> City Zip-,(,-, _Owner/Operator <br /> Check all appropriate services provided: <br /> T� Wastewater disposal O 3-compartment sink E� Electrical hool:ups <br /> q' Solid waste disposal 0 Food preparation P' Toilet and handwashing <br /> 1P Hot&Cold water for cleaning 13 Store refrigerated food q Potable water <br /> 1.7 Store dry food/supplies P' Overnight parking P Vehicle wash <br /> I, r•� cz ,hereby state that the information I have provided is current,true and <br /> correct to the`best of my know) ge, 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 sf Date <br /> 3. To be cpm feted by the V HEALTH Jurisdiction outside of San Joaquin Co. <br /> The —7nissary 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 />