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00 26'6 7� Aeo q '70 <br /> -¢ - S A N aJ O Q Q U I N Environmental Health Department <br /> " f COUNTY-- <br /> ;,�`_5:•,= Grectness grows her'­ <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 NameCvl� Q dAV© e r Lic. Plate# Q S : 6 3 L <br /> Owner/Operator Name�Uyc? ,33Gt ?-Iq ' <br /> Business Mailing Address Cfew S CDD r/d 9e qll <br /> City OCL O,�)State_j�AZip 9 Bus. Ph. Alt. Ph. <br /> 432 i , hereby state that the above information is current,true and correct to <br /> the best of my kn edge 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 alties. <br /> Signature �� 1 G Q/� Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name /1 FA# <br /> Address J f �G:L/y�" �, Bus. Phone d . 3 <br /> Cit Zi - Owner/Operator <br /> erator % . MeLll� <br /> Y t _ N N <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink M Electrical hook-ups <br /> ;r Solid waste disposal 0 Food preparation Ef Toilet and handwashing <br /> q Hot & Cold water for cleaning Eir Store refrigerated food 0 Potable water <br /> 0 Store dry food supplies 16 Overnight parking a Vehicle wash <br /> I, Z t�,i- , 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 notifv the D immediately. 1 <br /> Signature 4 Date S -7- <br /> 3. To be completed by t66 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 i Date <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />