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..(IFnRilt <br /> SQ N. Q Q U (N Environmental Health Department <br /> --COUNTY— <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 <br /> Business Name I nc1� 6u!�:iM is 11 S Lic.Plate# L4 U 41 Sq-61S <br /> Owner/Operator Name kJ13l,,J c.�J, Goki-1AdFa <br /> Business Mailing Address 2Y 66 513i5lul"IN =_ _ gw F_ <br /> City51'C(_k V- ,3 A; StateLAZip q Bus. Ph.2 M Ua �� ��Alt. PhOD(12'2S <<I R _S <br /> I, 1 1/t_� C4M_bF-941j ,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. <br /> Signature I IIS CA, bEelnlDate tob bp' L2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name / A / FA# <br /> Address /?tQ S c !i �� Bus. Phone f_- <br /> City Zip �15�`/() Owner/Operator r, <br /> Check all appropriate services provided: <br /> Wastewater disposal ❑ 3-compartment sink 6f Electrical hook-ups <br /> EX Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> a Hot& Cold water for cleaning ❑ Store refrigerated food Fyl Potable water <br /> C] Store dry food/supplies 13 Overnight parking Vehicle wash <br /> /G!zl e Z hereby state that the information I have provided is current,true and <br /> correct to the best of my krpCiedge, 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 notUy the E D immediately. <br /> Signature ���r// 1 «t Date <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 />