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SAWMAQUIN Environmental Health Departmer <br /> —COUNTY - - <br /> . r L!^ArnPscpoW hpi'^. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 completedIb APPLICANT <br /> Business Name C-( `Aeykcar)O IXItdeStZ? LI C Lic. Plate# �3cfb (A <br /> T� <br /> Owner/Operator Name COV'61�1r10 ��R,ynCtncrte-z <br /> Business Mailing Address e rr, �rl`t 4 ' C k'� f 2SS1 <br /> cit yi8e�Esto StateCA-ZipT�,SJ Bus. Ph. �1324 -- Alt. Ph�ere�c_� If�ee <br /> rn i�n Cd TEr'f)c Y)C eL , hereby state that the above information is current,true and correctto <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 discon i.nued, he permit holder must notify-the EHD. Failure to notify this office may result in permit <br /> revocation a/p\d penalties <br /> Signature l f�lAilill Date )�Z� <br /> 2. To be comple%eby COMMISSARY OWNER/OPERATOR <br /> Commissary Name LffliqFA# a0,2 49 3 <br /> Address ` (D } 'f}r' ►<I nl }� _ Bus. Phone �O`l - 7/ 2� �,If 9G, <br /> city L4;4 Zip. y j ��Owner/Operator V t. <br /> Check all appropriate services provided: <br /> 9(Wastewater disposal ❑ 3-compartment sink Electrical hook-ups <br /> Solid waste disposal O Food preparation Toilet and handwashing <br /> ® Hot & Cold water for cleaning ❑ Store refrigerated food [Potable water <br /> fS� <br /> 0 Store dry food/supplies Overnight parking Vehicle wash <br /> I, M5 LL _, 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 no a EHD immediately. n <br /> Signature Date .0 / 2- <br /> 3. To bb/completed b 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 />