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t <br /> 7 <br /> SAN J O A p U I N Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility •jCaterer <br /> Complete sections I and 2 If yourcommissary is located outside of Sart Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name u9BL-Fi I;RCGK `'u- Lic.Plate# <br /> Owner/Operator Name 'Y1bN]?5Oti <br /> Business Mailing Address '*t03lb V-ORV II LAM <br /> City SCOGIL"'CW State.�&Zip 95201 Bus. PhLL0)9%15.5V5'j It, Pht2t77) C'7tPt9 <br /> I, t 1aftti*k Ttc wp5pa ,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 Dale <br /> 2. To be completed"by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 0 Mwcs5cnA ArAZ'tf Cil FA# <br /> Address(QZ0 SCQCCLlh0fl40 Bus. Phon 'z? -E563q <br /> City LOd� Zip CK2,40 Owner/Operator to <br /> Check all appropriate services provided: <br /> Wastewater disposal C 3-compartment sink 0 Electrical hook-ups <br /> Solid waste disposal O Food preparation �II-Toilet and handwashing <br /> Hot&Cold water for cleaning 8 Store refrigerated food kpotabie water <br /> &S Store dry food/supplies tM Overnight parking Vehicle wash <br /> I, OpwimL--s" a74f r ,hereby state that the information I have provided is current,true and <br /> correct to the best b 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 a EHD immediately. <br /> Signature Date tCll��'GZ <br /> 3. To be cortfpleted by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in County. The above food facility meets the J <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 209 464-0136 1 www.sjgov.orglehd <br /> 4 <br />