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SAN.JOAQUIN <br />COUNTY <br />Environmental Health Department <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 />To be completed by APPLICANT <br />Business Name AHAR inIPMA/ Cu C Lic. Plate # <br />Owner/Operator Name 1 ,1- k¶ c <NIG )1 <br />Business Mailing Address 67 -2' f\r, 1-tit c 5--1 Lviqy Lt,R <br />City cm c-kkayi State t9 Zip eicol Bus. Ph.A I 11 Alt. Ph. 0 f- 405' <br />kr---vvveil__:\ S, , hereby state that the above information is current, true and correct to <br />the best of my khowledge 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 p nalties. <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name !\-7 k e ('C4 FA# <br />Address (OZO F--)_CICCC>(\\01 <br />(\c <br />- Bus. Phone c20°--- <br />City LC-6\ Zip Cic 2-40 Owner/Operator ‘R\f.,y-x\&0 UNIT! c <br />Check all appropriate services provided: <br />jo Wastewater disposal 'SO-compartment sink tit Electrical hook-ups <br />Solid waste disposal 0 Food preparation 0, Toilet and handwashing <br />itHot & Cold water for cleaning 0 Store refrigerated food xi Potable water <br />t 11 Vehicle wash <br />I 0,ONVCl , 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 EHD immediately. <br />Signature /7/ %<*"7 Date 63 /0(0 (--( <br />3 To be completed by the ENV HEALTHjurisdiction 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 j Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />0 St-1)0-1 °I <br />st OvCA <br /> <br />Date <br /> <br />0 Store dry food/supplies ia Overnight parking