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• <br />SANJOAQUIN <br />minor —COUNTY <br />,allSzor Greatness grows he <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 (-;-: 1/C--4U) 5 0 Lic. Plate # .C.) S- <br />Owner/Operator Name ACIA /4A 6t Oti I Z__ IA PI O Ak <br />Business Mailing Address 5_(-1/ <br />City376C1;1(1' A.) State Cr Zip9O us. Ph. 20 '430 12 Alt. Ph. <br />I, k),Y.cA ni3 I ,fr <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 />d pena <br /> Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name U L; i 0 M (' /11(7/Ct NO Udflc (e,04.0 reA# <br />Address) 71 7 S U ki Dij -----7 Bus. Phone -2,0 - 2 01 Cs' 5Clit-, <br />City57r---/C.) A-) Zip qs:-)c(':, Owner/Operator <br />Check all appropriate services provided: <br />xi Wastewater disposal tq-3-compartment sink (kr Electrical hook-ups <br />4t1 Solid waste disposal 'Ifi Food preparation pk Toilet and handwashing <br />i5( Hot & Cold water for cleaning if Store refrigerated food ,-Potable water <br />kr St re dry food/splies <br />i ( '6)(i 'S KA <br />ta-Overnight parking eVehicle wash <br />I, ti <br />f <br />, <br />, hereby state that the information I have provided is current, true and <br />corre t to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary o e EHD immediately. <br />Signature k_.-- Date y//q/)c)----i <br />To e 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 I T 209 468-3420 F 209 464-0138 I www.sjgov.org/ehd <br />PQ0945C1 <br />, hereby state that the above information is current, true and correct to <br />revocation <br />Signature <br />ties.