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SANSJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> G'reotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be'completed'b APPLICANT <br /> Business Name � Iiv CN Lic. Plate# yVA 3354 <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City S'�Cv'v z� State C Fl Zip q c%�IL Bus. Ph. Alt. Ph. <br /> 1, .l S,T , 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." <br /> Sig jure"" � Q Date 1�-C -s rlclae� �� <br /> 2. To be completed by COMMISSAR/Y/ OWNER/OPERATOR <br /> Commissary Name L, Ln/NI5ac i b M.c As-In FA# <br /> Address 1211 5-t4-" ,S� Bus. Phone (249133K-3rE 2 <br /> City �a�1�5kn Zip-C( Owner/Operator <br /> Check all appropriate services provided: ✓ <br /> �( Wastewater disposal P 3-compartment sink )4 Electrical hook-ups <br /> 4$ Solid waste disposal IN Food preparation U Toilet and handwashing <br /> Of Hot& Cold water for cleaning Or Store refrigerated food P Potable water <br /> IN Store dry food/supplies Overnight parking J@ Vehicle wash <br /> I, gark to i.5 /"ruz , 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 i4dDate 11/173h2 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in g�C'U . 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 notifyEHDif the status of their operating permit changes. <br /> REHS Signet , //,! j Date /I D u Zo Z <br /> j.?b15--t�4U 'W-12 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />