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SAN 10 A Q U I N Environmental Health Department <br /> COUNTY,.wr— <br /> Grectness crows 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 L I+OwnLRr� Lic. Plate <br /> e Operator Name H�(� � T S 106 H 6 HJUM A0, <br /> Business Mailing Address 6706 maN-7"AUBAtl AVE <br /> City_ T)('K'Fat4 . StateC�Zip q S, Bus. Ph. Alt. Ph. , 0 q5rZ_-x)43 <br /> I, , 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 H .4 =_ 7: •t,� i,,;rr1C��,� Date (� —1H 12013 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name (' `Y ii) Cr 0 4c-z_ ('fie✓ FA# <br /> Address 3 1-1 I Le m i C= v� Bus. Phone `aoc�- O'k\A%--- \1 \401 <br /> City S ?—a Ck� Zip <Y �r s�m-9''Ow er/Operator 'L <br /> Check all appropriate services provided: C, <br /> p Wastewater disposal 0 3-compartment sink E"ectrical hook-ups N Z <br /> E3 Solid waste disposal p Food preparation Uk"foilet and handwashing O 3 C <br /> Hot & Cold water for cleaning ore refrigerated food O Potable water 0 'Z F <br /> E3 Store dry food/supplies 0-'vernight parking O Vehicle wash > ;am <br /> I, hereby state that the information I have provided is current, true and U, C X <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility m D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the V1 ; <br /> commissary owner shall notify the EHD immediately. <br /> Signature � ,�,-,>, � / S'� ;,4 Date ) o <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 I T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />