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SAN 10AQUIN p <br /> Environmental Health Department <br /> 2 • '.;r z, <br /> jbr � ---COU N T Y -- <br /> °�,; Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 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 T j +. i PAN DEL V A L 4. E Lic.Plate# 4y 14, '7 <br /> Owner/Operator Name fE D 4 w ,z Q.• E V- A n<- 1 A <br /> Business Mailing Address )�(7 13 Ca ik t E rj i. ' A F C i S ; E Z � ! 1 <br /> City ✓`1 v o c ; -o _State c A Zip q 5 3 S ' Bus. Ph. 2 0 9 s y 9 rG 1 5 6 Alt. Ph. <br /> I,f. 'E (4 A 1 A , 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 Date it .11 - l Z' Z -� <br /> /46� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name CAI �LA�C�U1 —FA# <br /> Address Bus. Phone <br /> CityZip Owner/Operator t%l\ Ott W1V7 <br /> Check all appropriate services provided- these, 8e�v1 put Wered at -this fa U li-tLj <br /> Wastewater disposal - -sinkElectrical hook-ups )'/1b/23 <br /> j Solid waste disposal Toilet and handwashing 7j'.cTw9 <br /> Hot R Cold water fnr cJaaniA@ Potable water <br /> stere 14 Overnight parking 17 Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the b st of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to co ply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary win hall notify the EHD i ediately. <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in &.a4%&18US 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 /> RENS Signature Date Il 111P 12023 <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 />