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SR VoS4 39 -�_ <br /> SAN JOAQUIN Environmental Health Department <br /> ----COUNTY—— <br /> Grcot,ness s here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ti, 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 2es>Lkr-\�� rAe y%ka CkYO Cckr r "�v Lic. Plate <br /> Owner/Operator Name ?, kk4V\'0' y S:VAV f` <br /> Business Mailing Address -zci Z.9 1-tc_r r 13(y X <br /> City 54 LN e-, k J 6 y\ State_LLZip Bus. Ph. Alt. Ph. Qo 3 a`)-A ` 3 <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 Date i Z bt f ry Z 5 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ( vrIn1 (I,Jer10,4 Suj2DII FA# <br /> Address Ai f pvr- Bus. Phone `Z&`l (; 6 1 l T�,L <br /> City SL, - Zip Zv Ow len r Operator <br /> Check all appropriate services provided: <br /> 10 Wastewater disposal 01 3-compartment sink O�Electrical hook-ups <br /> ip Solid waste disposal 0 Food preparation FYToilet and handwashing <br /> 4 Hot & Cold water for cleaning Store refrigerated food �Y'Potable water <br /> 11 Store dry food/supplies �`J Overnight parking C Vehicle wash <br /> I, kgz4e��52( A�( h , 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 shall notify the EHD immediately. <br /> Signature �'� Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> _PfZ 0 S`4 2S I� <br />