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SAN�JOAQUIN p <br /> Environmental Health Department <br /> " ® �•` t —COUNTY- <br /> 9; o etP' 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 /> 1. To be completed by APPLICANT <br /> Business Name 1�_ I Cl Ic(A I I l �D C Lic.Plate# -* 35LI �� 3 <br /> Owner/Operator Name T ►/1005U) II0IIA44) Cf7VlNaS <br /> 'Business Mailing Address 170 67jX SII <br /> city '5*4*-' State b} zip- ,q 5Z05Bus. Ph.U1 ul ( 3I Alt. Ph. <br /> I,WAric' 1564) I(f1 p►'las C o n f IY✓!1`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 pltias� 4 /1 <br /> Signature //i/ Date �I ' A Z� <br /> ti2.Tobe completed by COMM ISSARY.OWNER/OPERATOR " -:., <br /> Commissary Name I i t' L I t I I 1 INC, FA# <br /> Address 1.100 4J • r,t�Yt�jJfGi� Bus. Phone <br /> City � Zip Owner/OperatorflyA V1 Cls e C) 11A WKS CorifY'eo,S <br /> Check all appropriate services provided: <br /> d Wastewater disposal E( 3-compartment sink If Electrical hook-ups <br /> Ef Solid waste disposal KY Food preparation Or Toilet and handwashing <br /> Hot & Cold water for cleaning G Store refrigerated food Lf Potable water <br /> G(Store dry food/supplies //����t�,����``Q"Overnight parking U Vehicle wash <br /> I,�Vj(lSCj) IjVIM1t3 CL)117Y6� S , 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 o r sh I�/notify EHD immediately. rr 22 <br /> Signature 7K � Date 1� 1-2 � 'Z7 3 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Coil <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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br /> 0 <br />