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SAN.JOAQUiN Environmental Health Department <br /> —COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a 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 b APPLICANT <br /> Business Name C �, t� ` h �- Zf Lic.Plate#i �1 _� '2j <br /> Owner/Operator Name /` <br /> Business Mailing Address SJ LLI ��ti <br /> City'-tf ;i- State- Zip Sdof= Bus. PhAoy- yY_-? - ` Ja411 Alt Ph. <br /> I, "S,%/V/Ct 'P5 "'2-2--o— <br /> ic�-o— 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_Izri penal//ti,es. <br /> Signature' VV —Date <br /> 2. To be corn leted by COMMISSARY OWNER/OPERATOR r <br /> CommissaryName LA FA# <br /> Address _qolco E rldky'a ve h Bus. Phone atlDq /1L� <br /> City A�c� Zip 6tS Zo5 Owner/Operator CAn;o ri tyle.-1-t <br /> Check all appropriate services provided <br /> FVWastewater disposal X 3 compartment sink ��Eljical hook-ups <br /> 0/'Hot <br /> waste disposal U Food preparation JT -let and handwashing <br /> 0 Hot&Cold water for cleaning 13 Sto refrigerated food �ble water <br /> o dry food/s lies ae Ovemight parking Vehicle wash <br /> I, a v/t/,',o.0 hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets alibmia Health&Safety Code requirements. If the food facility <br /> operator fails td'comply with the Gond" this agreement, or if this agreement is modified or cancelled, the <br /> commissarywner all notify the HD J • tatNy _` <br /> Signature <br /> 3. To be corn leted by the ENV HEALTH jurisdiction outside of San JoaquinCo. <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 209 468-34201 F 209 464-0138 1 www-sjgov.org/ehd <br />