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�ANJ0A0UIN Environmental Health Department <br />" C:H � `, —COUNTY— <br />Greatness grows here, <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections f and 2, ff your commissary is located outside of San Joaquin County also complete section 3. <br />W1 To be com leted b ' APPLICANT n <br />Business Name n A I'1 7 �� I4 n R A A A Lic. Plate # <br />Owner/Operator Name ^I � QSC-Yri P/N C1 N <br />Business Mailing Addr ss C4 4 o toy. <br />Cityj)[ck o (4(tA409tate-/ Zip GS 6 i Bus. Ph.209gi499 33 Alt. Ph. q2 S9006p0 <br />I, hereby state that the above information is current, true and correct to <br />the best of my knowledgeand agree u .1.2 my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin Coun Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinu , thepf r holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. A # r 9 <br />2. To be completed, b , COI IIMISSARY OINNERIOPERATO <br />Commissary N <br />Cityy1 Zipg Owner/Operator Ucn 0 /(Uafta.1 T <br />Check all appropriate services provided: <br />Wastewater disppsal A�-compartment sink Electrical hook-ups <br />Solid waste disposal &�ood preparation ,Toilet and handwashing <br />Hot & Cold water for cleaning Store refrigerated food ,0' Potable water <br />Store dry food/supplies Overnight parking ,Vehicle wash <br />I, 1,eftij , hereby state that the information I have provided is current, true and <br />correct to the bes f 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 owned shall ,!Pe EHD immediately. t ^ <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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 4683420 1 F 209 464-0138 1 www.sigov.org/ehd <br />e <br />