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AN�JOAQUIN p <br /> 4• ° Environmental Health Department <br /> Iwekt <' =COUNTY---- <br /> � ' Greotness grows hcr,_. <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 / p <br /> Business Name Lic. Plate#6 C7P1 h b <br /> Owner/Operator Name o-"j (d� <br /> Business Mailing Address ?�/ 411 <br /> city StateG�ZipCJQ� Bus. Ph.2riq !�?n2?/2 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. J <br /> Signature R(A,� l� ���QG_ Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La Comisarlo /t ton�¢83o FA# <br /> Address 01 5. 71 .5XwJ- Bus. Phone (20q') 338-3683 <br /> city 14VO6�e Zip ' 5'351 Owner/Operator (old 5*vr4% <br /> V <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal IN 3-compartment sink Pjl Electrical hook-ups <br /> Ip Solid waste disposal Food preparation IN Toilet and handwashing <br /> 13 Hot & Cold water for cleaning 0 Store refrigerated food 0 Potable water <br /> 0 Store dry food/supplies IM Overnight parking 13 Vehicle wash <br /> 1, M4rh UAIS- C.R/t , 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 /> y <br /> Signature / k—a Date y_ZS.121. <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 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 />