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OUIN <br /> SKJOAQUIN Environmental Health Department <br /> COUNTY— <br /> c to Greatness grows her.. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 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 NamekEN6 D1OGtZt Nei Y.9 <br /> ,V6Z Lic.Plate#--61 3 F 3 <br /> Owner/Operator Name h ,& <br /> Business Mailing Address <br /> City State ipBus. Ph. Alt. Ph. <br /> I,� _ hereby state that the above information is current,true and correct to <br /> the est of ml kn wledge and agree tb 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 G Date C966 �I <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UA-05M DU ,c k564 (S2 FA# <br /> Address 171� t�-) I2ei Bus. Phone <br /> CitySi�(.Ydry' Zipowner/Operator - ILGJP /! <br /> Check all appropriate services provided: <br /> p Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ❑ Solid waste disposal Food preparation ❑ Toilet and handwashing <br /> O Hot& Cold water for cleaning O Store refrigerated food ❑ Potable water <br /> Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> I, .'i/la /4 , hereby state that the information I have provided is current,true and <br /> correct to th4 best of mf 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 Il' —_Q� �— Date �Jh J�2f���� 2- <br /> 3. <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.QPlease notify EHD if the status of their operating permit changes./ <br /> REHS Signature <br /> /Pew- <br /> / Date `"✓�/ V 4 <br /> / !_ l r//� C/✓li--- <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 www.sjgov.org/ehd <br /> ad -" <br />