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uuiN. <br /> r'�'�r ` `•c��x�; SAN. IOAQUIN Environmental Health Department <br /> In 1-31 �: —COUNTY----- <br /> O Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <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 -T L_iY1't�?v1Q„q Lic. Plate# A-?? SS T?_ <br /> Owner/Operator Name AlAw' ,^ji ZIA <br /> Business Mailing Address 3 C'.✓�e �j'S-_ <br /> city State-UZip c Bus. Ph. Alt. Ph. <br /> I, , 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 J'11'10y1 _4jU1G�Y/Ya K Date <br /> ki <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName 1i CA /I �or !J�_FA# <br /> � { � �Address Phone <br /> City �v/e\ Zip C( S'Z L- Owner/Operator <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal tj 3-compartment sink Electrical hook-ups <br /> [$ Solid waste disposal @( Food preparation Ej Toilet and handwashing <br /> 10 Hot & Cold water for cleaning )p Store refrigerated food Ef Potable water <br /> It Store dry food/supplies Ba Overnight parking $I Vehicle wash <br /> 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 Z'S �� <br /> 3. 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 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />