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ryUIN` <br /> Q'� ° , SAN JOAQUIN Environmental Health Department <br /> " ►: ,, COUNTY <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 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 { , �\ a\N�- Lic. Plate# elz <br /> Owner/Operator Name LEAre ICS s I Y\4 <br /> Business Mailing Address f_v.S y <br /> City Ya StateL/�Zip C1 5� Q Bus. Ph. Alt. Ph. <br /> I, 4o y-me L i 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 /> Signature ktA_---j_ Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name R& Ny® FA# <br /> Address 3yl)_ £ 07,'w t" Bus. Phone <br /> City T(bdclo2 Zip 61S2_* (_ Owner/Operator 57a1f ct�..- _Chg <br /> Check all appropriate services provided: 11 t+, <br /> D Wastewater disposal 0 3-compartment sink 125-Electrical hook-ups O th er <br /> D Solid waste disposal 0 Food preparation Toilet and handwashing A m Z <br /> D Hot & Cold water for cleaning E11- Store refrigerated food 0 Potable water Q O <br /> Z30 <br /> 0 Store dry food/supplies R-Overnight parking 0 Vehicle wash mn <br /> I, hereby state that the information I have provided is current,true_yd X m <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food faces D � <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, L% C m <br /> commissary owner shall notify the EHD immediately. p F, D <br /> Signature__ICiu�s� K� Date /lbl2 3 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside 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 />