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S A N Q A Q U I N Environmental Health D partment <br /> f _l COUNTY S � lD7 ) I <br /> <. Greatness 91 -,s 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 I I Y'I e Y1 G 1 ��1Ct G� 1VPAL Lic. Plate# 7 L J <br /> Owner/Operator Name irn O►Y1(5, �`"�'T'Cart-eZ, TOn5 O W t t )C37 <br /> Business M i 'ng Address ( '71 rn G S <br /> City, �3� Bus. P �WA ��" e)O Alt. Ph. <br /> YC� State CIZip � �� <br /> ` ' �hereby state that the above information is current, true and correct to <br /> the best of m y knowledge and agree to utilize my appYoved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County E vironmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontin ed, the permit ho er must notify the EHD. Failure to notify this office may result in permit <br /> revocation an enaltie . <br /> j Date 133 [,)V�2 <br /> Signature <br /> 2. To be completed by C MMISSARY OWNER/OPERATOR <br /> Commissary Name U lW �U��i'��'l 1 -1'�)— —ly�� "G FA# <br /> Address ���1 �►�U �� <br /> Bus. Phone C` C 5 <br /> City ` ' Zip (, Owner/Operator +n <br /> Check all appropriate services provided: <br /> Wastewater disposal Cl 3-compartment sink O Electrical hook-ups <br /> Solid waste disposal V O Food preparation 13 <br /> Toilet and handwashing <br /> �j Hot & Cold water for cleaning C3 Store refrigerated food <br /> Potable water <br /> E3 Store dry food/sup lies CI Overnight parking Vehicle wash <br /> I, 1 r_(j �� , hereby state that the information I have provided is current, true and <br /> correc to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comply with th conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary to <br /> shall notif he EHD immediately. i - <br /> 13 C j �2 Q-�Z3 <br /> Signature <br /> Date ►cf <br /> r <br /> 3. To be com leted b 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 />