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SQN JQQ Q � � Environmental Health Department <br /> t <br /> ..___..COU N T Y _....- <br /> G rrar ' <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 /> ,� d PPLICANT q; <br /> Business Name AIil e fu ri GY I Lic. Plate <br /> Owner/Operator Name i (:Vk Cy GI W L) d V-J M <br /> Business Mailing Address Zi j� C1 t( FAQ d C'(A via L L V <br /> CitState C 14 Zip 9526 7 Bus. Ph. Alt. Ph. <br /> I,0q%rW ado&C,*w JZ� , 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 en (ties. <br /> Signature Date <br /> Oil efed b OMMISSARY OWNERIOPERATOR <br /> vl <br /> Commissary Name A (�A�6' h.,d- FA# <br /> Address e, y � ��� 1e2z, BUS. Phone G - y� " Z%���76) <br /> City d Zip gsal) Owner perator A X. C°-fZW <br /> Check all appropriate services provided: <br /> EJ Wastewater disposal 3-compartment sink ❑ Electrical hook-ups <br /> Solid waste disposal Food preparation ❑ Toilet and handwashing <br /> i Hot & Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies 1. Overnight parking ❑ Vehicle wash <br /> I, G GAS- Ck_flf � , hereby state that the information I have provided is current, true and <br /> correcf 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 sh II notify the EHD immediately. <br /> Signature �'�" Date — I — 20 2 ? <br /> ' dlction outside of SanCNV HEALTH 'uristFo o <br /> Joa uin., <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 />