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` SAN J O A Q U I N Environmental Health Department <br /> eVYi`' COUNTY--- <br /> F^Ga'' Greatness grows here. <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 LlY13 ] tP k Lic. Plate# <br /> Owner/Operator Name Uo( <br /> Business Mailing Address <br /> Cit yh(i�,�(a State /Lzipq!z�)(t Bus. Ph. 7,6 —32�Alt. Ph. <br /> { ((jcj p hereby state that the above information is current,true and correct to <br /> the best of my kn6wledge 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 a penalties. c 2 <br /> Signature Date Z l 2l <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName g�(,lc�JI�J �'p i1 zt 1 j`1 ItC�(� FA# <br /> Address LhL to Bus. Phone 20R - 6Ge- ��CS <br /> City S jcckf�p zip QjZJ Z Owner/Operator <br /> Check all appropriate services provided: <br /> O'Wastewater disposal AT 3-compartment sink Electrical hook-ups <br /> f3-Solid waste disposal 0-Food preparation a-Toilet and handwashing <br /> IT Hot & Cold water for cleaning U`8-tore refrigerated food O"Potable water <br /> B'Store dry food/suppliejs� 0 Overnight parking 0 Vehicle wash <br /> I, !�\M!`Q TU'L Q-0- , 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 owneLAhall notify the EHD immediately. <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />