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` <br /> SANJOAQUIN 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 by APPLICANT —7 <br /> Business Name M a to A Y`S 1 Le C r�ea ryl Lic. Plate# l0 L 7 / 03 <br /> Owner/Operator Name k CL k Ute( U u.i'-Yt 7 A. 5 "" <br /> Business Mailing Address �] 1 f Pj W Fry,Ayixz <br /> City _' of -+i-vi State CA Zip ^l�Bus. Ph. Alt. Ph. <br /> 1,_ 1j44njjpV Q Lr1,9OAP Sr ,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 Envir ental Health Department (EHD) requirements. If the use of the <br /> commissary is discontin d, the permit hoh t notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe <br /> Signature Date Z z <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name I CK Al 4 0 9 C_C C'R E A[V7 FA# <br /> Address 3 c Bus. Phone <br /> City S ^o CN-ToN Zip C'.A g5A�s O ter/Operator OwniER <br /> Check all appropriate services provided: N <br /> ❑ Wastewater disposal ❑ 3-compartment sink "ectrical hook-ups m Z <br /> ❑ Solid waste disposal ❑ Food preparation oilet and handwashing O :3 Q <br /> Z — _ <br /> ❑ Hot& Cold water for cleaning "tore refrigerated food E3Potable water n m n <br /> ❑ Store dry food/supplies 19 Overnight parking ❑ Vehicle wash n X m <br /> I, hereby state that the information I have provided is current,true and N X <br /> correct to the best of my knowledge,and meets the California Health &Safety Code requirements. If the food facility C M D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the C 3 <br /> commissary owner shall notify the EHD immediately. <br /> Signatures�J1r., �. a' z _ � Date 'r( <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.sigov.org/ehd <br />