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SAN 10 A Q U I N Environmental Health Department <br /> --COU NTY — <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete se'ctiohs 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 /> ./' e �/ �'_ �V`71� <br /> Business Name �Vr ;Per'i 0 oma Ae"m Lic. Plate# 'I 1 <br /> Owner/Operator Name J_�ar be I /t tace_27 <br /> Business Mailing Address 1 yao wa/n L4 5- <br /> City S-kcLk 4-pn State(J+ ZipG/5a05 Bus. Ph. �d0j)50- - 33a5 Alt. Ph. <br /> I, (.,,v k b,l 1 c4,/ , z- 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. 1 � <br /> Signature V t'-A t Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name �q A✓�� Saar"c / loc��s-- FA# <br /> Address <br /> , /a// 5. i �h � Bus. Phone C��9)�oa-5/ys <br /> City /telade5o Zip 25351 Owner/Operator <br /> Check all appropriate services provided: <br /> a-Wastewater disposal 0--3-compartment sink O'Electrical hook-ups <br /> p'Solid waste disposal 13 Food preparation Toilet and handwashing <br /> C'Hot & Cold water for cleaning M-Store refrigerated food U-Potable water <br /> ErStore dry food/supplies €Overnight parking C'Vehicle wash <br /> I, Qr� LvjS �J 21 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 owner shall notify the EHD immediately. <br /> Signature _ __ Date 03� /a3 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in01Y11S`aIAS 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 i 1 Z D2 3 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />