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SAN J OAQ U I N Environmental Health Department <br /> C G U N T Y-- <br /> COMMISSARY <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 ���� -t �ep� \- �� Lic. Plate# <br /> Owner/Operator Name e5\L'J <br /> Business Mailing Address P-oo-S <br /> City State0A Zip 5 Bus. Ph.(f i� 'VU72 Alt. Ph. <br /> I, , hereby state that the above information is current, true and correct to <br /> the best of my knowledge an 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 aQd penalties. <br /> Signature Date <br /> 2. To be completed by' COMMISSARY OWNER/OPERATOR <br /> Commissary Name C.oMMuu lT`( k<tTGE-kEI.t FA# <br /> Address `to til• GL. OoRAOo $T Bus. Phone <br /> City 5-r0C_LG.-M" Zip `tszoz Owner/Operator L.EoNEL -CAs-rku_o 1c0-FOUNDER <br /> Check all appropriate services provided: <br /> 14 Wastewater disposal % 3-compartment sink {ffi- Electrical hook-ups <br /> 14 Solid waste disposal 19 Food preparation Toilet and handwashing <br /> 10 Hot & Cold water for cleaning 0 Store refrigerated food Potable water <br /> fA Store dry food/supplies <br /> I, L.Eot EK-L CASTIL.L-a , 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 own hall notify the EHD immediately. <br /> Signature Date <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 /> W Sq q 010 <br />