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Environmental Health Department) OAQUIN partment <br /> —COUNTY— <br /> Greatness Jroirs here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility . Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed b APPLICANT c <br /> Business Name"S S 1%�{\ZQ� 'AL k%&4 � <br /> Lic. Plate# <br /> Owner/Operator Name C,Y _Ai d o Q-C,h,TCk W G aVr-P_ CC C1.bAV-'I r22 M ar✓huCc, <br /> T <br /> Business Mailing Address as J(: . C\}" <br /> Cit c), Statf-CO, ZipgS?)lb Bus. Ph.2Uq�A)'DO00 Alt. Ph. 'r <br /> ) QOt932 � <br /> I, l/ PkAxA'4b_11n1nUd UhUCA , 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 nenalties.� �j <br /> c�//�//� n+.'X/�-�t`y Date <br /> Signature 4 , 2� <br /> 2. To be com"leted'b COMMISSARY OWNER/OPERATOR <br /> Commissary Name L pup Z FA# <br /> Address 95 Vj - 10+'� S+ Bus. Phone ?.a - `ie <br /> City 7-y-6L(! Zip (31 53"1 b Owner/Operator llea vt _i e' M A u <br /> Check all appropriate services provided: <br /> �g Wastewater disposal ® 3-compartment sink 13 Electrical hook-ups <br /> p Solid waste disposal ® Food preparation ® Toilet and handwashing <br /> ® Hot& Cold water for cleaning ® Store refrigerated food �otable water <br /> ® Store dry food/supplies ® Overnight parking ® Vehicle wash <br /> I, R /�('K YVi tdaG , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledg , 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 owner shall notify the EHD immediately. <br /> Signature Date <br /> & T6,10616on 'letedt t V4HE-AL0THs drisdiaion0outsIde,of San.Joa uin,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 />