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SAN JOAQUIN Environmental Health Department <br /> CCUC,4TY- <br /> - �rrrl. -<<, ,- <br /> i <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ocaterer <br /> Complete sections i 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 pii �;IkCAL U—C- rr �Lic. Plate# <br /> Owner/Operator Name ��5 K 5 N <br /> Business Mailing Address '*t03P0 Y-r�1Zlll'f �.iht�1'F <br /> CitySTOGV—" 04 StateCA Zip ?MVI-Bus. Ph 9%5-5V54 Alt. Ph(�)9t%,'10 <br /> I, 1 NV$1k14 "TtOQApg 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 penalti <br /> Signature Date <br /> 2. To be com leted"by COMMISSARY OWNEWPERATOR <br /> Commissary Name 2 C FA# <br /> AddresstQ2C) Bus. Phon 22 `0?S 3q- <br /> City _Od 1 Zip Owner/Operator r o <br /> Check all appropriate services provided: <br /> Wastewater disposal "i 3-compartment sink tQ Electrical hook-ups <br /> Solid waste disposal © Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning la Store refrigerated food ,Potable water <br /> Id Store dry food/supplies Overnight parking Vehicle wash <br /> I, lissCiU a7+-e ra, _, hereby state that the information I have provided is current,true and <br /> correct to the best o 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 e EHD immediately. <br /> Signature Date 7_ <br /> 3. To be com leted 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 I Stockton, California 952051 T 209 468-3420 1 F 209 464-0136 1 www.sjgov,org/ehd <br />