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SAN JOAQUIN Environmental Health Department <br /> .-.{''10"U N TY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility(� Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section a, <br /> 1. To be completed by APPLICANT <br /> Business Name 14 FKUZt;4:",4 Lie. Plate# Ex:�J?ffd3 <br /> Owner/Operator Name �A. 'l4 ,d 1"A)4h roL5,,) j <br /> Business Mailing Address <br /> City S7oCL-1A3 State Zip�Bus. Ph.269- "14.1 ()23h Aft. Ph. <br /> l >5414.1 )41 9�41&Drr C ilk M , hereby state that the above information is current,true and correct to <br /> he 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 penal" . , <br /> Signature C f .&? Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Nam , oc V/ K JZO t) FA## <br /> Address.-) /J7 QUa, ) Bus. Phone 2k1)2 q k - y1 _ <br /> City 370C�JrrA) Zip QSL�() ( OwnerlOperator 7,� <br /> Check all appropriate services provided: �jc S70067 G <br /> Z Wastewater disposal M., 3-compartment sink D Electrical hook-ups <br /> � Solid waste disposal M+ Food preparation - iX,, Toilet and handwashing <br /> .�' Hot& Cold water for cleaning M Store refrigerated food 21 Potable water <br /> Store dry foo-d1supplies E-I, Overnight parking Vehicle wash <br /> i, WI /11e 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 falls to comply ith the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o eral al the EHD immediately. <br /> Signature Date_ ` 16 ',26-2 <br /> 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 Califomia 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.orglehd <br />