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ID <br /> SA N J O A Q U N Environmental Health Department <br /> COUNTY <br /> Gcl Greatnessgrows Isere. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4� Caterer <br /> Complete sections 9 and 2_ If your commissary is located outside of San Joaquin County also complete section 3. <br /> 'I. To be completed by APPLICANT <br /> Business Name CA X00 Lic.Plate#-71 V3 U 3 / .2— <br /> Owner/Operator Name 1110 -TO AUJ <br /> Business MailingAddress )ZOLA tAr\rwy <br /> ,Jt <br /> City K00M State­AZip 52 Bus. Ph._���f1'S(;�-� --Alt. Ph. <br /> I,_14aPIP , !0 rAeE.S ,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. ,— /7—�— -_ <br /> Signatur i1 _�� Date J1 11-71,202-3 <br /> 2. To be completed b • COMMISSARY OWNE�WPERATOR <br /> Commissary Name U•Y I UYl �,�lY= Truck lt'/7� FA# <br /> Address)-I 1-1 S UYV`t3r1 S1 Bus. Phone 26`1 Zq <br /> City ��0C 16/ ) Zip 9 S,�O L l�C Owner/Operator b,L I IQQtU 71 ieAab <br /> Check all appropriate services provided: <br /> Wastewater disposal 4 3-compartment sink Electrical hook-ups <br /> Solid waste disposal + Food preparation Toilet and handwashing <br /> Hot& Cold water for cleaning Store refrigerated food 02 Potable water <br /> ` 1 Store dry food/supplies Overnight parking 0 Vehicle wash <br /> I, Ue5l/ , hereby state that the information I have provided is current,true and <br /> correcito 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 owners ll noti a EHD immediately. J —� <br /> Signature Date <br /> 3. Tobe com"leted by the ENV.HEALTH.'urisdictio"n'",outside°'of:Sala-J.oa, 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 /> REHS 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 />