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SKJOAHIN Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <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 M C t 5 Lic. Plate#Vq - <br /> Owner/Operator Name P\ N b j D D L <br /> Business Mailing Address � S <br /> 71— <br /> City `0 Statef Zip­l25 Bus. Ph. %I- Y:�)] Yi'I��Ait. Ph. !-� 2-90 <br /> , <br /> I, [ TUD f\ o E E C E , 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 penaltie <br /> Signature - Date o2 S 2()2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary NameU I OAU Wt lr2j'N 6 ��W-C F Iy!��-FA# U <br /> AddressIll S - U I I I � ST Bus. Phone (1V1- 2C� S-I �P <br /> City S-a(K I U Zip qS Z W Owner/Operator ElbS I R E N E T1 �DL <br /> Check all appropriate services provided: 0\l f� I C, <br /> Wastewater disposal 3-compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Hot&Cold water for cleaning Store refrigerated food Potable water <br /> Store d food/sups sS Overnight parking Vehicle wash <br /> I, ` 7 , hereby state that the information llhave 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 complywith th conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shclll noti he'EHD immediately. C <br /> Signature Date D2 J 1 .7,ol <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />