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SAN JOAQUIN Environmental Health Department <br /> ..—COUNTY-- <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 Y Ls Lic. Plate# <br /> Owner/Operator Name <br /> Business Maili g Address �!^ lr <br /> City DY <br /> f State h- p qs 40 bus. Ph.r? X-,2Alt. Ph. <br /> I, hereby state that the above information is current, true and correct to <br /> the best of my yrowledge 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 discontinu d, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe If . <br /> Signature Date <br /> com feted b COMMISSARY OWNER/OPERATOR <br /> Commissary Name eluw W,5 5u Y7 AZ- k� FA# <br /> Address Z�2U S 34t-rk tc- Bus. Phone LaI2zv 833 Y <br /> City 4,0V/' zip '16Z ye Owner/Operator fi1yj W)-r"— A4- _ <br /> Check all appropriate services provided: <br /> M//Wastewater disposal Qi3-compartment sink M Electrical hook-ups <br /> JJ" Solid waste disposal PO ood preparation P//oilet and handwashing <br /> M(Hot& Cold water for cleaning ore refrigerated food iILY PPptable water <br /> 9/§tore dry food/supplies q�vernight parking +'Vehicle wash <br /> I, hz+ecA�- 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. aJ <br /> Signature-�5 Date l[4 -Z(f- ZZ <br /> com feted by the ENV HEALTH 'utisdiction onside 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />