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SAN J D A Q U I N Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s Caterer <br /> Complete sections 1 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 �iCLLtF fpkl�GHI Lic.Plate# C$ <br /> Owner/Operator NameC/��G-56� C({RISTtE/✓ Yo[inl� <br /> Business Mailing Address W1 E 67-226C7- <br /> City l LLL_ crR S State Zip o Bus. PhL-1)Z7p"7977 Alt. Ph. <br /> 1,a-aa5 ems! ��n9 C� 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 md penalties. d <br /> Signature Date 2- <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name � �Al c1 ck t�Ens f ER FA#11 <br /> Address /7/7,5, a lyd i 6AJ � Bus. Ph�oJne w o?) <br /> City S�K�TOSa. C� Zip_.5oZ0 r; Owner/Operator Igg f /Ix)gL)c <br /> Check all appropriate services provided: Nd 7— S%�/QR G,E Or FBO® 7-R 4?ZC(V <br /> a/Wastewater disposal D 3-compartment sink Electrical hook-ups <br /> }l solid waste disposal Food preparation Toilet and handwashing <br /> L—, Hot&Cold water for cleaning Store refrigerated food visotable water <br /> Store dry foodisupppllies Overnight parking h Vehicle wash <br /> I, 1 % <br /> 77 RIS b 6 , 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 owners flnot ediately. <br /> Signature Date <br /> 2- <br /> 3. <br /> 3. To be completed 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 wvLm,.sjgov.org/ehd <br />