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SAN J OA Q U I N Environment Heauth Department <br /> COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 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 com leted by APPLICANT II <br /> Business Name (\f f f.�1 116 Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address SZO A t2nr4 A ve <br /> City 16CLj-&A Statei Zip CIS215 Bus. Ph.1516-11,, 11(o4 Alt. Ph. <br /> 1, l j,nc Qlgiv ibeLK ,hereby state that the above information is current,true and correct to <br /> the best of my kno edge 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 com Pleted` b COMMISSARYR'OWNER/OPERATOR <br /> CommissaryName L'G�,��„ttt � Ind 4, LWI _FA# <br /> Address 2-4{ UO- S. A%rj2tT4- L vim..; Bus. Phone Eoci - 9 l - / f 6 e. <br /> City S-k1r id 49 Zip 9 (7 o6> Owner/Operator <br /> Check all appropriate services provided: <br /> ® Wastewater disposal 0 3-compartment sink 1Xf Electrical hook-ups <br /> If Solid waste disposal d Food preparation 0 Toilet and handwashing <br /> ® Hot& Cold water for cleaning KI Store refrigerated food iW Potable water <br /> Of Store dry food/supplies W Overnight parking R Vehicle wash <br /> I, , hereby state that the information I have provided is current, true and <br /> correct to the43esfff 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 /-Z-4 zZZ <br /> 3. To be completed by the ENV HEALTH -urisdiction: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 /> RENS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />