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SA N J OAQ U I N Environmental Health Department <br /> —COUNTY--- <br /> COMMISSARY <br /> OUNTY---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 W1ex 'T-a a(es' ) Lic. Plate# yV 2ZZ� <br /> Owner/Operator Name Jt✓'S�S f�'tct:i KPS/PS <br /> Business Mailing Address 1j 3S t4nk-ct(✓1G ?'Jcj,K <br /> City ,SIL,--CtiL, State y#Zip c _j Bus. Ph1,�20���{�( �t-f 7/ Alt. Ph. <br /> I,�)Q.SvS ma'leo 4x ues , 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 a ti <br /> Signature Date <br /> 2. To be c rnleted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name lV e!c '(_aM Gi,tf--,S FA# <br /> Address 5,35-W. R- re i'Lli Lict Y Bus. Phone <br /> City S;z,G(G v. Zip 972-oY Owner/Operator JesvS M4; eo ley" <br /> Check all appropriate services provided: <br /> ®Wastewater disposal 21/3-compartment sink 13Electricalhook-ups <br /> ED/Solid waste disposal CDFood preparation Eir"' oilet and handwashing <br /> 13 Hot & Cold water for cleaning / — <br /> Store refrigerated food fdPotable water <br /> ®Store dry food/supplies 01 Overnight parking 11111"Vehicle wash <br /> I, sus 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 s all otify the EHD immediately. <br /> Signature Date <br /> wl ' <br /> �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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />