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SAN !OAQU!N 'Evv""Alro��[�w�c�nteA Henakh [���Q�61 y eU <br /> CCNU NTY--- <br /> air."+.. <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 com leted by APPLICANT <br /> Business Name 18 CO3 U L A ulk- 17 1 C Lic. Plate# <br /> Owner/Operator Name A KL 0 ;)iC . 5AIUC167-2— <br /> Business Mailing Address 0(0 hA A le 1' A UL-1- <br /> Cit -<AQ <br /> City-<AQ Cl /J State_CA Zip q Q GBus. Ph.Sl k� X3`1-I`_g Alt. Ph. <br /> ¢� (QCI"� 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 pe s. <br /> Signature Date_4&Z <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary NameyL�J it vU Cl'11 ?I NC-7 M CK C j.;,;A) ;LFA# <br /> Address a 'w i O u, 51 Bus. Phone ( (,(A Ci k- S <br /> City -[tai[��fa'�L' Zip O'S Owner/Operator A -hi �-,�() <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink + i Electrical hook-ups <br /> Solid waste disposal D Food preparation N Toilet and handwashing <br /> Hot & Cold water for cleaning 0 Store refrigerated food R Potable water <br /> _] Store dry food/supplies M Overnight parking ' Vehicle wash <br /> I, A"1 i2l T(e o , 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 owne s�h �lltlii'fy the EHD immediately. <br /> Signature iL- Date l�!�/X02.3 <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 1 Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />