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SANJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness 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 /> FtT <br /> Business Name IfAY•�)6 P Z 61i-ChQn Lic. Plate# <br /> Owner/Operator Name 6) UJUM �jtvk.y�7 <br /> Business Mailing Address lq. q "Qp.- 1e � C'.ty-c' P <br /> City Ut X:l�-}f�"(1 State�Zip 9�-- Bus. Ph.ja 33�- 1a'IQ Alt. Ph.&50- 2cg--5R gy <br /> I, C4 ul 1".) HAVA-144- , 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 /> 4 <br /> Signature Date <br /> 1 <br /> Commissary Name \ FA# <br /> Address 1021) 0.CC('MAN Q_( t_6 Bus. Phon D ZZ —633 <br /> City 1 I'NCV1 Zip ff�2 --kb Owner/Operator b 66( <br /> Check all appropriate services provided: <br /> j Wastewater disposal 3-compartment sink Electrical hook-ups <br /> e <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Sf Hot& Cold water for cleaning k1 Store refrigerated food Potable water <br /> l /Store dry food/supplies Overnight parking 61 Vehicle wash <br /> OY <br /> I, l AM(SSCfI4 ) k7h , 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 no'y the EHD immediately. <br /> Signature Date <br /> /7 Z <br /> 3' To be`completed by the ENV HEALTH jurisdiction outside <br /> 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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />