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SAN: IOAQUIN Environmental Health ©eparrsIt <br /> —COUNTY— <br /> `: Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility e 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 <br /> _NeXtCCA(\cx m010,= I V%JCK Lic.Plate# 80141CL S <br /> Owner/Operator Name M ccv t� Winch e2 <br /> Business Mailing Address '-f128 F, S 1 A4 N c4ye4 <br /> CityStoC(-FOY1 State Cc( Zip 'ASLIS Bus. Ph. Alt. Ph. <br /> I, Mot r k c( SC-^&e L , 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. t ++ <br /> Signature V".4%ef 5�LCvt@y Date I ZO ZZ <br /> 2. To be completed�- by n COMMISSARY OWNER/OPERATOR <br /> CommissaryName l�'l(i i7�tnr c (n r)n4 CLAWSFA# <br /> Address us. Phone ZeGr - S'C / 1516-6 <br /> City 12_44 ZiP__ j Owner/Operator Ulla <br /> Check all appropriate services provided: <br /> 13 Wastewater disposal GY3-compartment sink Or Electrical hook-ups <br /> X Solid waste disposal 00 Food preparation .6(Toilet and handwashing <br /> Hot & Cold water for cleaning ly Store refrigerated food E� Potable water <br /> Store dry food/supplies Overnight parking V'Vehicle wash <br /> I, 2sn�S IZ�b lvJ hereby state that the information I have provided is current,true and <br /> correct to t e 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 /> ' D <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.sigov.org/ehd <br />