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SAN JOAQUIN Environmental Health Department <br /> —COUNTY-- -- <br /> s_ <br /> u,�?otness grows here. <br /> COMMISSARY AGREEMENT , q, <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 L 4F Irzal 43//: Lic.Plate# ��7/ 7 <br /> Owner/Operator Name D z 22 e_ &VL" <br /> Business Mailing Address �l <br /> City. yState el4zip (3Bus. Ph.2D q 92A U 2 2(AIt. Ph. 59L&m f- _ <br /> I, 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 /> revocatio / <br /> Signatu Date Z9 le, �. <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName CU`S' m,0s� V'7-61CCO- FA# <br /> Address (07b T!K- Bus. Phone 2Z< L— 3 <br /> City LO& zip 'RS 0 Owner/Operator a4tM6M 00Aoc UC( <br /> Check all appropriate services provided: <br /> `i� Wastewater disposal I$L3-compartment sink JI Electrical hook-ups <br /> Solid waste disposal JZ Food preparation OgToilet and handwashing <br /> Hot & Cold water for cleaning fKstore refrigerated food 4 Potable water <br /> (/Store dry food/supplies l�Overnight parking Vehicle wash <br /> I, l �11�<, fly Cot hereby state that the information I have provided is current,true and <br /> correct to the best of 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%e EHD immediately. <br /> Signature Date zz I& <br /> 3. To be co leted 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.sigov.org/ehd <br />