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s <br /> SANJOAQUIN Environmental Health Department <br /> i 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 �15 J Lic.Plate# <br /> N (� Y ( •� <br /> Owner/Operator Name d C- 0 UI L-� <br /> Business Mailing Address S -SC <br /> City �+y i1))State A Zip Y.S r Bus. Ph. Zq qV VBGLAIt. Ph. <br /> I, Ake, r/1'IZS , 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 penalties, / L, <br /> Signature_ ��0e— A• Date OSl116( �7 <br /> 2. To be com leted b ;.COMMISSARY OWNER/OPERATOR <br /> Commissary Name G57444A-i!:r r y FA# <br /> Address 6 Z�,, tS —56 L re*-1-eti At : iL _Bus. Phone (Z 0'() ?LW — 0 a 3'y <br /> City 4.0 b,' Zip 15?_1/0 Owner/Operator A 1rje*j VW OGl­c­ <br /> Check all appropriate services provided: <br /> (Wastewater disposal a M'3-compartment sink ®'E`lectrical hook-ups <br /> ®Solid waste disposal (&ood preparation ®'I oilet and handwashing <br /> ®'i-lot& Cold water for cleaning ®tore refrigerated food Q1 Potable water <br /> Store dry food/supplies C1FOvernight parking 0--Ve-hicle wash <br /> I, ,474 e6- 4;-,•w---r>c r y , 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 �r� �� ��Z'— Date 1 lees — Z� <br /> .3,:T6,b,".d""'-'Oldt6d:b;. the ENV'HEALTH,.'urisdic�ion:�uts de;ofy.San:tJ�a�uin:'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 /> Wosg0101;3 <br />