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SAN J OA Q U I N [E-n vlirronomenW Heafth Department <br /> - --COUNITY--- <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 com leted by APPLICANT <br /> Business Name s o" Lic. Plate# ` J? 2 Q <br /> Owner/Operator Name ,t L <br /> Business Mailing Address lok r I Yi Ii,C 1- A ki-r' <br /> City STCKTo/✓ State_CLZip I.5' e, Bus. Ph. 2jX-64% 3--5-?g--Alt- Ph. a'-29 -�/o�, �;/L�-8,?,5 <br /> 1, nno;�n pLe fP/i , K 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 /> Commissary Name (_n 6 Cyr n,,, 64 4r a FA# <br /> Address 2 cl- Vu S. Ain en.s-L GLc� us. Phone <br /> City u�V/l —Zi' <br /> ips Za6 Owner/Operator z 2 S, <br /> Check all appropriate services provided: <br /> M Wastewater disposal 0 3-compartment sink Ek Electrical hook-ups <br /> M Solid waste disposal W Food preparation K Toilet and handwashing <br /> N Hot & Cold water for cleaning , Store refrigerated food `A Potable water <br /> 9 Store dry food/supplies Overnight parking Vehicle wash <br /> I, _ hereby state that the information I have provided is current, true and <br /> correct to the 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 (1/ 6 i 12 Z- <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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />