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SANAOAQUIN Environmental Health Department <br /> —COUNTY— <br /> 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 /> & ` <br /> Business Name US e:L PR//?To 01ft RLI Lic. Plate# 6� 3� /62 <br /> Owner/Operator Name f o/a SUc) ' --T-0fym <br /> Business Mailing Address �67-6 6rfe WSVMy-oU l.W LA� <br /> City$(yc l :A- Lv\� State G&Zip0-(�- Bus. Ph. Alt. Ph. <br /> I. Itrv.lq SUc"l ,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 Date / /�g'/ Zb 2- <br /> F2—. To <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name f lid(p 111 C14TER 1 >ti Ctit T uCk LNC F# <br /> Address 17/ 7 S, Z( //©41 5T Bus. Phone C?2et,2?6 <br /> City57D-C(«rL. (fA Zip?5526,9 Owner/Operator OWAJC-k <br /> Check all appropriate services provided: <br /> Wastewater disposal M 3-compartment sink 0 ElElectrical hook-ups <br /> G/-Solid waste disposal t7' bod preparation 1r Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food Potable water <br /> f <br /> UlStore dry foo�d/supplies Ci'Overnight parking O Vehicle wash <br /> ��� / <br /> I, (AAQ C) , 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 owners II notify the EHD immediately. <br /> Signature Date <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 />