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P (� 5 -1 -700b <br /> r � X02- 6 <br /> S A N ,J OA Q U I N Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 Namey �. _Q, , " Lis 4 ) 6 Ata4l_iG. Plate# <br /> r <br /> Owner/Operator Name \f i 4 uv UN rx i C vO <br /> Business Mailing Address Z303 7 rLtc)I b1d bf <br /> city 0(00 State CA zip 5206 Bus. Ph. I'lo 30 - 27AI� <br /> I, y�1 `"-- t11kr1r5 —, 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 ounty Envir mental Health Department (EHD) requirements. If the use of the <br /> commissary is disconti ed, t permit hot r must no' pe FH@ Failure to notify this office may result in permit <br /> revocation and al s. <br /> Signature / 4 Date <br /> 2. To be com let -by COMMISSA OWNEMPERATOR <br /> Commissary Name LA& �a� P1 7 FA# aD2-7 49 3 <br /> Address_' (p Z t2r 14.4,, p rJ Bus. Phone aO`} <br /> City "�_Zip 9_ Owner/Operatorf-ZVe— <br /> Check all appropriate services provided: <br /> 01 Wastewater disposal 0 3-compartment sink Electrical hook-ups <br /> Solid waste disposal ❑ Food preparationToilet and handwashing <br /> E3Hot & Cold water for cleaning 13JJ <br /> Store refrigerated food [jd PPotable water <br /> ❑ Store dry food/supplies Overnight parking IV/Vehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledgeand 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 own hall no 'fyl' a EHD immediately. <br /> Signature Date 7 2- <br /> 3. To b com leted b the ENV HEALTH 'urisdiction 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 /> X1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 46rr8-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> �lor..UI)IhAe_fL2 QT;lhllnil G )r^ <br />