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�U'", SANt�10AQUIN p <br /> °� ;-�`° Environmental Health Department <br /> "Ir t ; 4 ` 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 _ C"OS M4 rl-�-11 Y' 11 V Lic. Plate# Y 61 1 VZ,ty <br /> Owner/Operator Name q-I I AS 10 L <br /> Business Mailing Address PD V30"<X �54- <br /> ,f <br /> City' State�1 Zip ° LDS Bus. Ph.%�`� �'�� I��' Alt. Ph.21 '"1 1 "�G <br /> 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 /> Qj -2y-2 3 <br /> Signature( �> `t � Hca Gl Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName t%I (I r L I d(I o l Ne, FA# <br /> Address UQBus. Phone 2()<'1'- W e <br /> Owner/O �yl os c-D 1111 it cotyeolsrr <br /> City ��� ZiP 101620'+ erator P <br /> Check all appropriate services provided: <br /> U1 Wastewater disposal El 3-compartment sink Ef Electrical hook-ups <br /> of Solid waste disposal Lf Food preparation 61 Toilet and handwashing <br /> 114 Hot& Cold water for cleaning Q Store refrigerated food E( Potable water <br /> Store dry food/supplies Er Overnight parking [Vehicle wash <br /> 13 CM tw"As 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=EHD immediately. <br /> Signature Date 01-21 -2-3 <br /> y <br /> 3. To be com leted by the ENV HEALTH jurisdiction outside of San Joa uln 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 T 209 468-3420 i F 209 464-0138 i www.sjgov.org/ehd <br /> ( d <br /> I <br />