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SAN JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness <br /> COUNT`f----Greotneis env avg h(- <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 com feted 6 APPLICANT <br /> Business Name t_ i n n C Lic. Plate#5 <br /> Owner/Operator Name C L� ) I L Z ) I "1 I 1. P-N IN N D LT <br /> Business Mailing Address 1\ <br /> City sr ) . NState',,^^ � U"k ZiBus. Ph. Alt. Ph. 1 7 J <br /> I, C AV DI ft 14 <br /> F F(]8--ND I- 2-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 i co nu d,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation an na ies <br /> Signat Date <br /> 12. T6 be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Namey N t U rkU NCS ��� �,�I Nf L <br /> Address M1 � U IU J Bus. Phnnel(20,q ) Z� J <br /> U -- l �(� <br /> City �C-1—�lJ NZ Nip 1 _ ) Owner/Operator g-t,U E: /)�-C N E_ C6 <br /> Check all appropriate services provided: <br /> > Wastewater disposal 3-compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Hot&Cold water for cleaning Store refrigerated food Potable water <br /> Store dry��food/sup lies Overnight parking Vehicle wash <br /> 1, �E l K- u G'� , 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 owners ll notify WHD immediately. <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 /> RENS Signature Date <br /> 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> PC Osq ls�� L) <br />