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SAN JOAQUIN tnv� ranmenW Hea th Oepaiilment <br /> -COUNTY-- --- <br /> COMMISSARY <br /> COUNTY- ---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 Completed by APPLICANT <br /> Business Name=I ao-' `(1 CS7o r %la _ Lic. Plate Ua LXM33 <br /> Owner/Operator Name_4 ck > mv, I N ("o rvw Z- <br /> Business Mailing Address 3,21 W dcL4 mss+ <br /> City Soo J -+c)N State C-RZip_q52pf2__Bus. Ph. 7(R722-12-j It. Ph. <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 /> revocation and penalties. <br /> Signature lk'L f N (7oNLL Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> -[`/Commissary Name ( 'qirofo, (" ring Scram, " FA# <br /> Address 2-Y go S. ,4L r p rt (rc,�, Bus. Phone 2-c;'7 - 6/- /�i✓ti 6 <br /> City Seri ,&�.an Zip T( Zo—Owner/Operator Re4,&a—_V:jiln '47 <br /> Check all appropriate services provided: <br /> Wastewater disposal IIF'3-compartment sink W Electrical hook-ups <br /> IfSolid waste disposal i ; Food preparation Wl- Toilet and handwashing <br /> V Hot& Cold water for cleaning Store refrigerated food gr Potable water <br /> Store dry food/supplies Pff Overnight parking �Vehicle wash <br /> (, 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_3 <br /> �zZ <br /> 3. To be Com feted 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 />