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.OrnWnj �. <br />_':- SAN:.,JOAQUIN Environmental Health Department <br />—COUNTY— <br />Greotness grows here. <br />COMMISSARY AGREEMENT <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 />Business Name 'rz} (L_� a�(_) Lic. Plate # 7f 2rZ '5�'fI <br />Owner/Operator Name ube'4b7 <br />Business Mailing Address '%%(al,-) hLi OR 6t A MJF <br />Cityr StateLZi05DX Bus. Ph_ Alt. Ph. <br />I, A Axis fftl Ism , 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. 2 /sir'/ <br />Signature �/��'!/V` Date GCS <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name ('C.(I1•6r-nr.. i:aJf`e/'rhsf 0� jp,Ql�__FA# <br />Address 2'1410 S. XttWr4- us. Phone 2a� - <br />City 1QjMC4+!:2d Zip 15, 7zPA wner/Operator�� �r <br />Check all appropriate services provided:: / <br />Wastewater disposal O -compartment sink C—(/Electrical hook-ups <br />/Solid waste disposal O/C <br />preparation 113 Toilet and handwashing <br />Q/Hot & Cold water for cleaning P3 Store refrigerated food €7/Potable water <br />,; Store dry food/supplies Overnight parking pNehicle wash <br />I, Rg:!6z_� '` -Ao, e.l '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 <br />3. To becib*16fed'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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 4683420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />