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SAK. JOA UIN <br /> Q Environmental Health Department <br /> �ti t COUNTY <br /> 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 /> Business NameI� I ��� ti� 1"1 1 I L_&Q L �y_•L;Lic. Plate# '6S-�5 11 <br /> Owner/Operator Name <br /> Business Mailing Address 1(13 (I ukjAL(, <br /> City -(CIjGy State Zip cl,-5 1IBus. Ph. Zuij '�;'Q '-Irb<Alt. Ph. <br /> I, tU, j)ftyl U b_Qi4 C-7,L,ytf:g4, 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 discontinu the ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> ;V <br /> revocation and pe � / ? <br /> Signature Date !U <br /> A . <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName()kA V%U <br /> Address )III U V U A) Bus. Phone <br /> City ci10(.K-7o Aj Zip (Ts au Owner/Operator 'AeT 71 eAoc) <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal 0 3-compartment sink 0 Electrical hook-ups <br /> q Solid waste disposal D Food preparation M Toilet and handwashing <br /> ®' Hot& Cold water for cleaning 0 Store refrigerated food ('9 Potable water <br /> 0 Store dry food/supplies 0 Overnight parking IS Vehicle wash <br /> I, 'j 1Af L2 0 , 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. / 7 <br /> Signature �� Date !U! c5)1A4 ✓ <br /> j 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 1 Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> Pk OSS V13 <br />