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4 JUAWIN �� I �l � I � I� � � I� I I r �� r � l : �' J D ��� p a l� u !i f `� Pitt t <br /> Y -- <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 b APPLICANT <br /> Business Name 4 z9 Z LII Z I Lic . Plate # ��i U1 <br /> Owner/ Operator Name �°' y � � �,,�� 01.419r l <br /> � _ �J . � � er- � <br /> Business Mailing Address Y/ �/ . I A17 X) 4VU <br /> City State Zip SBus . Ph . T�Q 1Z 1 Alt . Ph . <br /> 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 . Date <br /> 12a To be completed by COMMISSARY OWNER / OPERATOR <br /> Commissary Name � ) AJ 10 �° � Z 1 i 6 l ' &&Zl d FA# <br /> Address / `fid 7 6 C) iViV ld � � Bus . Phone C .2. 0 9 _) 2c/ k 5 cl <br /> or <br /> City -7Q , zo= )O <br /> No '' S �� 0 (91 Owner/ Operator ael 11 <br /> Check all appropriate services provided : Ak 570! 67 <br /> GX Wastewater disposal 0 3 - compartment sink j=1 Electrical hook- ups <br /> Solid waste disposal c1 Food preparation CRA Toilet and handwashing <br /> Hot & Cold water for cleaning 6 Store refrigerated food 10 Potable water <br /> L ? Store dry food /supplies ? Overnight parking Vehicle wash <br /> I , Iq Ar. � / e , 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 oAner shall n tify th HD immediately . <br /> Signature Date <br /> 13 . 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 /> RENS Signature Date <br /> 1868 E . Hazelton Avenue Stockton , California 95205 I Ti 209 468 - 3420 1 l= 209 464 - 0138 1 md>jw . sjgov . org /ehd <br />