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SAN :,JOAQUIN Environmental Health Department <br /> —COUNT"— <br /> , �:reac.,es �..., •<.. <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 /> 1. To be completed by APPLICANT <br /> Business Name SO VVLCLt 1-6LC _0S L- Lic. Plate# g l g� <br /> Owner/Operator Name sO Pl t Lv A <br /> Business Mailing Address , di(� VyLaf l tyk 4y e- <br /> City S+O(k+6n State�c"-d"'7 "Zips a Bus. Ph. 0q gq'W�0Ph. <br /> I, 3'O>t,14,0 4- C/4-wy , hereby state that the above information is current,true and correct to <br /> the best of my knowledge and a ree 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 4G Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> / C.1 <br /> Commissary Name l 0wx\l��( \ ,fz;Z -Pcni FA# <br /> Address (07,0 -L S(.)LCC('>rhP,( l� p 4i5t Bus. Phon Z q- ' 33 <br /> city U& Zip gSZ'-�O Owner/Operator <br /> Check all appropriate services provided: <br /> `0 Wastewater disposal V 3-compartment sink Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> Hot& Cold water for cleaning Store refrigerated food Potable water <br /> , L Store dry food/supplies Overnight parking Vehicle wash <br /> I, OAI SSU7-h'( , hereby state that the information I have provided is current, true and <br /> correct to the best o y 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 n ify the EHD immediately. ��"" <br /> Signature Date W 16174 <br /> ZZ <br /> 3. To be coftleted 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />