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SAN 10AQUIN p <br /> . .- Environmental Health Department <br /> . ' COUNTY <br /> r1'.rrVFa�. Grcarne.s 3i� .� Bare. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 9 and 2_ if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be com feted by APPLICANTI <br /> Business Name �.— /'' ``L�"C.Plate# -1q <br /> Owner/Operator Name �� y1f'i2 r <br /> Business Mailing Address 1 _ _s AGrA,1j4 , <br /> City G4/StatZip SLvBus. Phi�}5,��7���Alt. Ph. <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 an enaltie <br /> Signature i Date 5 ha. La <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName U 0t lift C" ll,IZI A/16 !O UCk �D, I FA# <br /> Address f I Jv1 Q Aj Bus. Phone-2q) Z,(4 5 !1�J <br /> I k <br /> City '-)JOC4<�16A. i Zip_q. :�j JQ � Owner/operator (Vyu _ �1 Y7�k�il <br /> Check all appropriate services provided: <br /> Wastewater disposal )9 3-compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Hot& Cold water for cleaningStore refrigerated foodM Potable water <br /> Ston dryfood/supplie Overnight parking ehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correct t the e t of my knowledg ,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with t nditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ow r sh off a EHD 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. Plea$e notify EHD if the status of their operating permit changes. <br /> RENS 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 />