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SAN )QA Q Q N Environmental Health Department <br /> —COUNTY-- <br /> COMMISSARY <br /> COUNTY _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 /> APPLICANT s' <br /> Business Name I v\a r 1 S C O L L C Lic. Plate# <br /> Owner/Operator Name J 0S C, 1'Y1 U Y1y '1 �"\\ C" <br /> Business Mailing Address (o y n (Q '1D G. CA YZ u vi '+' 1 3 3 <br /> City 5�-c-k� r_' State C Ya-Zip S 24D Bus. Ph. (6 50 63S�It. Ph. <br /> I, _� 65.E m�"v-9-� \I \ �� C% , 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 penalties. <br /> Signature �dC "^'y �f��� ��� Date- lo Lo <br /> `�4.: t1t Ieted b OMMISSARY OWNER/OPERATOR <br /> Commissary Name A �/��C- I FA# <br /> Address 11W �° C.tC�x l Bus. Phoned <br /> City d Zip o Owner perator <br /> Check all appropriate services provided: <br /> Wastewater disposal C9 3-compartment sink C] Electrical hook-ups <br /> Solid waste disposal Food preparation C] Toilet and handwashing <br /> Hot & Cold water for cleaning O Store refrigerated food ® Potable water <br /> Ca Store dry food/supplies U Overnight parking C] Vehicle wash <br /> I, f22QY'c4?—Yt cA , 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 com ly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner all notify the EHD immediately. /, <br /> Signature --- Date to _ 2S <br /> di,* the ENV HEALTH jurisdiction outside of San Joa un 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 />