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SAN 10AQU I N Environmental Health Department <br /> - COUNTY- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 CA L7 L307AA2ffi LQrA `5 Lic.Plate# yV <br /> Owner/OperatorNameytift) [ ^621;,5 GU ) A Obbeio <br /> Business Mailing Address 1U1 OU) 1,04 4 F C1 <br /> City &I State Bus. Ph. Alt. Ph. <br /> hereby state that the above information is current,true and correct to <br /> the best of my knowled and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and Sa oaquin Cou Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is disco ed,thp p97nit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe s. J/ <br /> Signature Date �7/f A 023 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name (,)AJJQA) CA16XZAf(7 T fC <br /> Address /1.12 S, 0-AJJQA) S7 Bus. Phone (ZOct 1,2!2&— wf/fes_ <br /> Cit y,c-M(MA.) Zip 6 Owner/Operator <br /> Check all appropriate services provided: IVO 5 7046 C <br /> f8 Wastewater disposal 0 3-compartment sink ❑ Electrical hook-ups <br /> 11 Solid waste disposal 13 Food preparation 01 Toilet and handwashing <br /> IN Hot& Cold water for cleaning ❑ Store refrigerated food 11 Potable water <br /> ❑ Store dry food/supplies 13 Overnight parking 0 Vehicle wash <br /> 1, 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 otiner stbAIL46tify the EHD immediately. <br /> Signature Date7 13o?Q-A 3 <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 1 Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />