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SAN JOAQUIN <br /> Envlronmental Health Department <br />--COUNTY -- <br />r". oreatot7ss orowc <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 />To be completed by APPLICANT <br />Business Name <br /> <br />Jurf fr ffitAte cf; Ito/4 <br /> <br />Lic. Plate # <br /> <br />Owner/Operator Name 5, Y1 <br />Business Mailing Address /61.(2 <br />City Aitoi-k,-- State OA- Zip ets-ss ,-} Bus. Ph /c.M Ulf -- Alt. Ph. '‘'‘7 5x <br />I, )11,-(4_,Ti )11`14ALA , 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 penaltie <br />Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name es CK' TN/. Co <br />Address 3 t\'.. ry /3 ON t_ Bus. Phone -ci— eAkA Mko\ <br />City .0 ro 7-or-v- Zip 0-0- el 5 oS Owtier/Operator <br />Check all appropriate services provided: <br />ia Wastewater disposal <br /> O 3-compartment sink <br /> • ectrical hook-ups <br />[C11 Solid waste disposal <br /> O Food preparation <br /> t-1 and handwashing <br />0 Hot & Cold water for cleaning ,• SfOre refrigerated food <br /> O Potable water <br />CI Store dry food/supplies <br /> rpdvernight parking <br /> O Vehicle wash <br /> , hereby state that the information I have provided is current, true and rji 7,7 <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 <br />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 I 1 209 468-3420 I F 209 464-0138 I www,sjgov.orgiehd <br />Signature <br />FA# <br />0 <br />Date 3