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SAN J O A Q U I N tnA ronmeota@ Health Department <br /> --COU NTY- -- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections f 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_ Vl(�f fta\i )T) _ Lic. Plate# -� n 3 <br /> Owner/Operator Name <br /> Business Mailing Address ienre Ave <br /> City/q�k(\CV_Adn StateCA Zip gS215 Bus. Ph510--1)o y7<vy Alt. Ph. <br /> 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 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName&hr rht (' la,g5+ FA# <br /> Address ?_aUL,) S, A)rp2t r-k wL; _Bus. Phone 2ucl - Sh l - / f 6 ra <br /> City S L,C of nq Zip_ � (72 )67 Owner/Operator L-e14V` o I J <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal M 3-compartment sink It Electrical hook-ups <br /> ® Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> ® Hot& Cold water for cleaning K3 Store refrigerated food W Potable water <br /> E4 Store dry food/supplies M Overnight parking X Vehicle wash <br /> I, ¢ �--- , hereby state that the information I have provided is current, true and <br /> correct to th f my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator falls 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 /> �IZo Z Z <br /> i <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.orglehd <br />