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<br />SAN JOAQUIN <br /> <br />Environmental Health Department <br /> <br />COUNTY---- <br />Fost-t &oco <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 ./ a (0) i-ktj ,7* a illefeke Lic. Plate # (AP çb41 <br />Owner/Operator Name i--:-C/C)--/CD 67072_4L., <br />Business Mailing Address 17 ) Am . <br />City 3 k---1-7) Staten) Zipc/576 7' Bus. Ph. <br />noi, G , 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 pemlties. <br />SignatuFe.. <br /> <br />Date <br /> <br />2.-To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name (---0 Art, (My F FA# <br />Address 47,471 ars Aft• .(illial/A/e Bus. Phone 0-dy Yjx2rz.. <br />City (..6 Z i p V() Owner/Operator 6/7 e f <br />Check all appropriate services provided: <br />J21 Wastewater disposal qr 3-compartment sink pt Electrical hook-ups <br />qt- Solid waste disposal D Food preparation El Toilet and handwashing <br />Hot & Cold water for cleaning 0 Store refrigerated food is- Potable water <br />O Store dry food/supplies ;a- Overnight parking gir Vehicle wash <br />Ille/X e , hereby state that the information I have provided is current, true and <br />correct to the best of my knowled ,'and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with th6 conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shaiDotify the HD i diately. <br />Signature Date /0-2--91- /70; r <br />3. To be completed by the jHEALTHjUrisdiction 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 20'9 464-0138 I www.sjgov.org/ehd <br />Alt. Ph.