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C P__O 's � P0 t'o �,P, <br /> SAN -10AQUIN Environmental Health Department <br /> COUNTY--- <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 !'' �5/U f(/1 ( q Lic. Plate# 3 lT2 <br /> Owner/Operator Name g Il -01 Lel S <br /> Business Mailing Address /2-0 V ` ZO Q3 2Z <br /> City 5L2(" StateShLZip 9�0_203 Bus. Ph. Alt. Ph.2� �s� q5 Z Z- <br /> 1, <br /> I, Z A 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 enalties. <br /> Signatur Date <br /> 2. To be completed bY COMMISSARY OWNEMPERATOR <br /> Commissary Name �2 e':rz_ FA# <br /> Address 6o Zc)' Bus. Phone 00'1 ZZ y 3 5V <br /> City Z-a0r` Zip 5 ZYd Owner/Operator �iTdr�' 1�-j <br /> Check all appropriate services provided: <br /> �stewater disposal Cr3-compartment sink Electrical hook-ups <br /> W'Solid waste disposal �Fo d preparation Toilet and handwashing <br /> I(4 HOt & Cold water for cleaning 'Store refrigerated food potable water <br /> tore dry food/supplies C�Overnight parking Wehicle wash <br /> I, />1L7i',-"-- <<14114'-'.5��, 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 <br /> EHD immediately. <br /> Signature ��" Cy" Date l <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />