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SAN 10AQUIN Environmental Health Department <br />COUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility c Caterer � (Z 3 S C� 3 <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 Name �_ i M e7Ct Cit nO rxl tx <br />Owner/Operator <br />VU t_LC Lic.Plate#r <br />Business Mailing Address_J - C) f W Ad C2 S� <br />�Ye�Ccr: vo- r- lelu, <br />C42 cziE f StatdC_% Zip��i3�� 7 Bus. Ph. 2s--q3Z`f �i�AIC Ph_f <br />I, ` i �', I n (A R47) (4Y)?J 2 , 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 />2. To be completet.by COMMISSARY OWNER/OPERATOR <br />Commissary Name_L <br />Check all appropriate services provided: <br />,(Wastewater disposal ❑ 3 -compartment sink <br />® Solid waste disposal ❑ Food preparation <br />;p- P'wz3 <br />c <br />Electrical hook-ups <br />O/Toilet and handwashing <br />❑ Hot & Cold water for cleaning ❑ Store refrigerated food P(Potable water <br />❑ Store dry food/supplies Overnight parking at'/vehicle wash <br />-Sq>_ Yr yt E_ _, hereby state that the information I have provided is current, true and <br />correct to the best of my knowledgefand 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 noji 7Ve EHD immediately. , <br />1 3. To Wcompleted by the ENV HEALTH iurisdiction 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 <br />1868 E. Hazelton Avenue i Stockton, California 95205 i T 209 468-3420 i F 209 464-0138 I www.sjgov.org/ehd <br />i iM10 tqd di'LSS 1.;'eo C.6 10 '- ay 2A -Goy <br />