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.a <br /> SAN JOAQUIN Environmental Health Department <br /> COUNTY-- <br /> . <br /> Greatness grows here. <br /> (2— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility m 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 _WaS 5 A 0 'ISL Lic. Plate# 1 _�� Ii Z_ <br /> Owner/Operator Name C I e A SIA K)C-0 (,,N A 2 Pr k i A) a <br /> Business Mailing Address 22,0 L Q C 1 l.(' lA IJ r <br /> City S"ft?CK-fc,11,� State_LA Zip C1 S.3 Cri Bus. Ph. BCCI -3qj) A9&J. Alt. Ph. <br /> I, Cie, - &AILA: 'i Cy14Z'1 -9/�li'1/ , 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 IJVt ���—h�C U Date 5/3Q/ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName IJ Q,UQ- CAlt:�J/Ut7 1 I(` u,, C jO etVA# <br /> Address 1111 `S- i,) U,,0-0 I Bus. Phone (ZOLO <br /> City SMCKIW3 Zip 95--20 (y Owner/Operator u-T- :TI a ion <br /> Check all appropriate services provided: U: AS P (� L` <br /> p Wastewater disposal 13 3-comparfinent sink 13 Electrical hook-ups <br /> p Solid waste disposal p Food preparation 13 Toilet and handwashing <br /> 13 Hot & Cold water for cleaning O Store refrigerated food ® Potable water <br /> El Store dry food/supplies 13 Overnight parking ® Vehicle wash <br /> I, �) 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 with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner s all "Itify the EHD immediately. 2 <br /> Signature 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 />