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/�4t��. SAN J OAQ U I N Environmental Health Department <br /> i .& i COUNTY <br /> c���Foar'�f 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 /> 1 1 n <br /> Business Name 1V TU <br /> , \ ��,� I"I a1 1 �� 1 L L. �VLic. Plate# >S 'S `"�7� <br /> Owner/Operator Name )'k) )U 8 V 11,1,0 0 Ill C'1 k;`L I( r � i 2- <br /> Business Mailing Address 1�1 '� G� Lki q L L <br /> City T j�a:Cy StateZip C1 7 j )(•;Bus. Ph. 26�1 `j Lj `J '(-, Alt. Ph. <br /> I, V A L)0- L64 6s,lit;,KZrL,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 discontinL!Fd, the ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe ?. <br /> Signature Date <br /> f <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name OA_J, V,'L) ��/37t✓ iVL� 7PULe_—j:•4 ZZX FA# <br /> Address �� I r� �) lJ�(;IJ `�� Bus. Phone ,Z C L1—Z 0 `-11 ('2 <br /> City `St G(K-70 AJ Zip �� S,�0(`, Owner/Operator 71 CA 0L) <br /> Check all appropriate services provided: <br /> p Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> q Solid waste disposal ❑ Food preparation ® Toilet and handwashing <br /> ®' Hot & Cold water for cleaning ❑ Store refrigerated food (9 Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking m Vehicle wash <br /> I, /,-A 19 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 ith the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o ner sh notify the EHD immediately. <br /> Signature r �/� 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 />