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S A NJ OAQ U I N Environmental Health Department <br /> COUNTY <br /> �. r Greotness grows he, <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 /> 1 . To be completed b APPLICANT <br /> Business Name A L DN,-S-O'S C Gi(43 L R 0 c= Lic. Plate# 7� 9 �U <br /> Owner/Operator Name G E kM h(\� p f-KEZ- <br /> Business Mailing Address -�Cg(� MDA <br /> CitySTDC 'Mt�Statef-AZip .,2 U Bus. Ph. <br /> Y11A ' C Z <br /> � fP _ , 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 completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name VAtl D YL 07�dA(A(6N 71RL(Ck CE1ti7CA FA# <br /> Address (7I 7 S. axle btil ,5/- Bus. Phonec'�6.yam/ -1� y 'g Ll <br /> City�1'1 &] Zip �S�E Owner/Opera`t�or 11KE / A80 a <br /> Check all appropriate services provided: (k) DILI4 1 <br /> ❑ Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Store dry foo supplies ❑ Overnight parking C1Vehicle wash <br /> // <br /> I, //�/lnn�6 , 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 ownerMalotify the E immediately. <br /> Signature Date 7 Z Z <br /> 3. To be completed by the ENV HEALTHjurisdiction 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 />