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SAN J QA Q U I N EnArr®nfinental Health Department <br /> --COUNITY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ,; Caterer <br /> Complete sections 1 and Z If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT Q <br /> LL <br /> Business Name (a c OK rif Ye VQ, Lic. Plate# � �0 U <br /> Owner/Operator Name L ' a"Cr a CA <br /> Business Mailing Address vth S�- V\ <br /> City KUy\A UG Sta\tejLZip q SAABus. Ph.6S0 YH S i I I'A Alt. Ph. <br /> I, Ae5qt&�' (lig, D Q"9 , hereby state that the above information is current, true and correct to <br /> the best of my knowledge and a ree 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 �l 6 ! -Z l <br /> F2_T0 be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name r l' FA# <br /> Address 2 V j 4. 3 t-&A l.�'—�a Bus. Phone_ZU S6 <br /> City SL Cf 4 Zip_ S,Z+? Owner/Operator j q�' p1'b v <br /> Check all appropriate services provided: <br /> a'wastewater disposal of/3-compartment sink � lectrical hook-ups <br /> Solid waste disposal /Food preparation oilet and handwashing <br /> M" <br /> 101/ of& Cold water for cleaning Store refrigerated food Votable water <br /> tore dry food/supplies Overnight parking aq/vehicle wash <br /> I, �asaP 5 Qi J�4J 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 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.orglehd <br />