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SAN J O A Q O I N Environmental Health Department <br /> COUr1 I Y <br /> Greutness q: h,- <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 bv APPLICANT <br /> Business Name 1 U C _ l ( ,j f _ (�� (�� __Lic. Plate# �j Z Z <br /> Owner/Operator Name KA IAn( L t-fj &A_1n <br /> Business Mailing Address <br /> Cityrj)J(; IL JU,J State_/�Zip f ��l�J� Bus. Ph.2,..4i - `)7o 3'�33 Alt. Ph. <br /> Ij-\ACC� ALU.-ry �-lLj) i'�Iv%L(-, 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 / l(, c�_ Date <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name U fV' i rli L ASG 12 �C1C� �4 �; r� U2r # <br /> Address 1:1�A U fid U�L "� Bus. Phone 2-Q(- <br /> City �)j 0 CC"i OA-) Zip C-j `�t�l t L^ Owner/Operator �Q(,, Y—ery� -T) yt,,,c(o <br /> Check all appropriate services provided: <br /> V Wastewater disposal ❑ 3-compartment sink El Electrical hook-ups <br /> tl Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> M Hot & Cold water for cleaning ❑ Store refrigerated food Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking 19 Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> corre 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 th EHD immediately. <br /> Signature Date___ C <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />