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SAN .JOAQUIN Environmental Health Department <br /> —COUNTY-- <br /> ;,,,c=' Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ 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:com le#ed by APPLICANT <br /> b` ae4+`k" +i <br /> BusinessName �CUIW(A IFPVIT 60 WLS Lic.Plate# �L' <br /> .IU qH9 <br /> Owner/Operator Name �-(2I STI N R 12- 9_(A1 Z <br /> Business Mailing Address S Z t Vh to r aeC <br /> City cpnTStateZip 9.53. Bus. Ph.2( q10cf J29 ZAIt. Ph. <br /> I, V4kSt n a_ T, VVIJ, ,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 pe aIties. <br /> Signature Date .2 U 2 2- <br /> 2. To be completed by COMMISSARYOWNER/OPERATOR <br /> Commissary Name 04DdV GA7ER1N4 %RUCK 1C&WZ7kFA#` <br /> Address 17/ 7 S. r�/�l/vN sr Bus. Phone�'�/ <br /> r n <br /> City .5T044C1b- tj Zip 2SZ04 Owner/operator <br /> Check all appropriate services provided: <br /> astewater disposal ❑ 3-compartment sink 17 Electrical hook-ups <br /> olid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot& Cold water for cleaning ❑ Store refrigerated food otable water <br /> ❑ Store dry food/supplies ❑ Overnight parking ❑ Vehiclewash <br /> I, h RT -71423-00 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 all notitrhe EHD i mediately. �y <br /> Signature iY _7 Date <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.org/ehd <br />