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UP7UrA� X-. <br /> SA NpJ OA Q U I N Environmental Health Department <br /> NJ4COUNTY <br /> `.9,. Greatness grows he F. <br /> n... 01ive Disua'uduor. <br /> t Co <br /> COMMISSARY AGREEMENT `' 14 xa, j <br /> TudockCA95380 <br /> Mobile Food Facility ♦ Caterer 2094344= <br /> Complete sections 9 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 Co & ( I SCi Y, 6 Lic. Plate# u q/ 9/6 <br /> nn� <br /> Owner/Operator Name r�06,e,(-•t V l� lqa r'47 <br /> Business Mailing Address �J� L1✓1yl Ge <br /> CitI — StateM Zip 9 Bus. Ph. Z��"6��` U�6� Alt. Ph. <br /> —, 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 discontinR=_0 <br /> lder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penaltie <br /> Signature `` Date `3 70 Z��" <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 110 Q"(°S <br /> Address 1q'3 (t oc, K Bus. Phone (zo) 6/ 3�l- Z a <br /> City LA Y 0 ( Zip qG/t��' Owner/Operator/"'l'c &'/ qtn <br /> Check all appropriate services provided: <br /> p''Wastewater disposal Imo"3-compartment sink O'Electrical hook-ups <br /> e Solid waste disposal E 'Food preparation 0'Toilet and handwashing <br /> id Hot & Cold water for cleaning d Store refrigerated food Cf Potable water <br /> d Store dry food/suppli s Ef Overnight parking Vehicle wash <br /> I; T_ <br /> rrM t J' qeA , 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 ao.WAhe EHD immediately. <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> 'The commissary is located in 5+r t(r1 cs Iet"5 C<xc y. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. Thea e checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. 2 <br /> REHS Signature Ia Date 's <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 />