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SAN _JOAQUIN Environmental Health Department <br /> COUNTY— <br /> Greatness grows here. <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 bII II ,APPLICANT <br /> Business Name'Tt v- � W ' 1A< -Tv k_/' Lic. Plate# <br /> Owner/Operator Name_ k SC,' KjCj l GI Q n <br /> Business Mailing Address '1C1 <br /> _ STS W Lo� _w L,6 AWL <br /> "11:J <br /> City �► StateLAZipar)?lI Bus. Ph.2tA- SA IYZAlt. Ph.W1-" OF/ O <br /> I, rWA16 LAn hereby state that the above information is current,true and correct to <br /> the best of my knowledge an gree 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 a allies. <br /> Signature Date <br /> �l(V LL <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name comY n I.SScu vala FA# <br /> Address 13>01 S - S�x.c rz. wev� �T _ Bus. Phone Z04- ZS 7 3 <br /> City Lx-DJ s Zip q SZ Lt GJ Owner/Operator f he/N-c:.) )_4 ecf rz i I-e 7 <br /> Check all appropriate services provided: <br /> %Nastewater disposal ❑ 3-compartment sink electrical hook-ups <br /> �V8olid waste�disposal ❑ Food preparation 4Toilet and handwashing <br /> 14iot & Cold water for cleaning ❑ Store refrigerated food ��otable water <br /> ❑ Store dry food/supplies vernight parking chicle wash <br /> I, k�e> ✓� .n�C hereby state that the information have provided is current,true and <br /> correct to the best of my knowle e; nd meets the California Health&Safety Code requi ements. Ift a food facility <br /> operator fails to comply with the dltions of this agreement, or if this agreement i modified/,.r,- <br /> 13. <br /> , cancelled, the <br /> commissary ow 6�shall no5tjythe F mediate) <br /> Signature Dat To be completed by the ENV HEALTH jurisdiction outside of Safi 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 209 468-34201 F 209 464-0138 i www.sjgov.org/ehd <br />