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S A N-]0 A 0 U I N Environmental Health Department <br /> COUNTY <br /> Greatness gro.,� bp.—re,. <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 by APPLICANT <br /> Business Name C QAT9LAA1A '5 Lie. Plate# HV K'2a 03 <br /> Owner/Operator Name IAy,5(/A) "pL lV 0() LA /j 6-Moe 2-4 <br /> Business Mailing Address &/L) <br /> City �7c�CK Tc7Aj State_Ch Zip 9S"�ICS Bus. Ph.20q 0`i- )I-Alt. Ph. <br /> I, /4 6ri /AJ .(tel cwlxzf d f��L¢fa'e by 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 � t-r/� •�/��is+�(/��j 4 Date G7 ��(�11.201-3 <br /> 2. To be completedby COMMISSARY OWNER/OPERATOR <br /> Commissary NameNy ()lj I AIG-LfNd-t heUCK CE&&A# <br /> Address /7/ 2 6 ()AjiVA) j Bus. PhoneUOS) 2, .�f I �2 <br /> City S_1()(,L ),U Zip 01S,Xo( Owner/Operator :41CA06 <br /> Check all appropriate services provided: /VO — 5%01Zk7 <br /> (a Wastewater disposal 0 3-compartment sink 0 Electrical hook-ups <br /> p Solid waste disposal 0 Food preparation 17 Toilet and handwashing <br /> ® Hot & Cold water for cleaning 0 Store refrigerated food 0 Potable water <br /> 0 Store dry food/supplies 0 Overnight parking 0 Vehicle wash <br /> 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 w'th the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary own shall oti a EHD immediately. <br /> Signature Date t/��L <br /> 3. To be <br /> 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 />