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Environmental Health Deparrtmeml. <br /> SANJOAQff <br /> --COUNTY-- <br /> COMMISSARY MISSARY 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 /> T. Toibe open letedib APPLICANT <br /> Business Name . a L L1 Lic. Plate# <br /> Owner/Operator Name l <br /> Business Mailing Address d De— <br /> city StateZip 5 O Bus. N, q-)f-5 f l It. Ph. <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 /> Signature Date <br /> 2. To be:Com leted.'sb COMMISSARY OWNER/OPERATOR <br /> Commissary Name I)i�1• `��(�. %l%L FA# <br /> Address, ,ZV ,4 ,', Bus./Phone,/)lU%' �//L�/_- �/S 7D <br /> City Zip `�S �G-K Owner/Operator it, All, <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink I% Electrical hook-ups <br /> Solid waste disposal 0 Food preparation 14 Toilet and handwashing <br /> Hot & Cold water for cleaning ® Store refrigerated food EL6 Potable water <br /> SSJo/re dry food/su plies / Overnight parking ( ': Vehicle wash <br /> I, l_C�/(/�(%� Z"ZAb'l/ 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 cond'tfbns of this agreement, or if this agreement is modified or cancelled, the <br /> commissary oy r er shall notify the-51 )immediately./- <br /> Signature � �/ 71� 6L•G/G C__ Date <br /> 3-.LTo be,com teted.?+if1, 3th.0 ENV HEALTO-I''unsdiption outside 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 />