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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />Lic. Plate # 3-7-16e8 "(1 <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />'1,11 ,r'fb be completed by APPLICANT <br />Business Name4v t v2 )c.,(1\.\ c-cetd -Tkr-uck <br />Owner/Operator Name ''')V\k TY1C)k-efr/C3 <br />Business Mailing Address /06 S• <br />City çr1reYJfr StatisCpZipot 7-363 Bus. ph.ea7s---co6-? Alt. Ph. <br />90 rO. Ylq j.,42 an ., 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 />Signatur Date 2 /2 <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />FA# Commissary Name A-Z-lec.",_ (1(mvsh i•s_xe/ <br />Address <br /> o ,_5' etGra-kfrt Ye> <br />City 4-01) /' Zip r5 zqc <br />Check all appropriate services provided: <br />(z_01) zzy - g-3sy Bus. Phone <br />Owner/Operator Abc/ce,aro <br />rl"Wastewater disposal <br /> <br />O"-compartment sink <br /> <br />Electrical hook-ups <br />al/Solid waste disposal <br /> <br />O Food preparation <br /> <br />X.Foilet and handwashing <br />I3Hot & Cold water for cleaning <br /> O Store refrigerated food <br /> <br />W4table water <br />0 Store dry food/supplies <br /> O Overnight parking <br /> i2</ehicle wash <br />A Z4c6.1_._. , 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 g— — <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 I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />vRoS32-9-Su