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�- -_ Environmental Health Department <br /> SAN J OAQ U I N <br /> ` tii - COUNTY <br /> Greatness grows here. <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 completed by APPLICANT <br /> Business Name L Eb�� C L ,J L Ll E N S E Lic. Plate# i i�) <br /> Owner/Operator Name � I VI VS <br /> Business Mailing AAddress <br /> City <br /> t� t St(a�ted ZZipgSCSBus. Ph. 121 ZAlt. Ph� <br /> 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 <br /> L <br /> 2. To be completed bCOMMISSARY�OWNER/OPERATOR <br /> WNER/OPERATOR <br /> Commissary Name U � V <br /> AddressI J v � � �,i Sr <br /> � t <br /> Bus. Phone -- 20 t <br /> City TP L h), A Zip �5 �L� Owner/Operator I USS <br /> Check all appropriate services provided: <br /> ` Wastewater disposal 0 3-compartment sink 0 Electrical hook-ups <br /> Solid waste disposal 0 Food preparation 1 Toilet and handwashing <br /> Hot& Cold water for cleaning 0 Store refrigerated food Potable water <br /> 0 Store drysi food/suppliesC1 Overnight parking Vehicle wash <br /> I, P"� ! r f .1 y F TI ekb 0 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 n r shall notify the CD immediately. <br /> Signature �2� �l Y�l- (� .J4`1,�y�t(y'� Date MCI <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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> TV)S' �gwo <br />