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S A N J O A Q U I N Environmental Health Department <br /> --COUNTY-- -- <br /> Great, <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 t ,\ t n' <br /> Business Name L�j iN I `t V A Lic. Plate# 'T I `t K__ u( 1 <br /> Owner/Operator Name <br /> Business Mailing Address Q� j L <br /> City Sf11(r-V N State(A Zip 5aa'Bus. Ph.( 'tl-(fi) `t'0?" q Z%lt. Ph. <br /> I, E VN K (a 1;! i I K IL , 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 dis tinged, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p aJ `, r <br /> Signature Date L tic I <br /> 2. To be co I ed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name VN IO N CRr 2_V--1 6 1_14(K-A NCJ S � <br /> Address—n 1 n S - V fel l a pA .fir Bus. Phone 2c) 2q �6, - nS <br /> City STT)CKU N Zip 6151 .P Owner/Operator (Z�'� 19-f TI <br /> Check all appropriate services provided: <br /> Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> T` Solid waste disposal ❑ Food preparation )Toilet and handwashing <br /> Hot& Cold water for cleaning ❑ Store refrigerated food '�t Potable water <br /> ❑ Storre�dry food/supplies C ❑ Overnight parking � Vehicle wash <br /> Kn� `, 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 ow r s II notify th D immediately. <br /> Signature Date ; <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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />