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R jq v\ <br /> ANJDAQUIN Environmental Health Department <br /> -COUNTY <br /> 2 2 <br /> •:+c,Fcr��`•�' Greatness crows 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 /> m Business Nae� T <br /> A`l 1��_ s 1 A (` /7 r --—Lie.Plate# U 2 te c) <br /> Owner/Operator Name 8 9 LA- f JA to L K E_ <br /> Business Mailing Address 25�3 L[A 12-1 F:-02 D l-)P <br /> City 1,-Op I State G4 Zip `7S 40Bus. Aft. Ph OGOZ40 ^16(�3 <br /> I / I/�-,I c-J A , 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 per ' older must notify the EHD. Failure to notify this office may result in permit <br /> revocaf penalties. <br /> Signatu <br /> 1 Date S 2-1 I <br /> 2. To be completed by COMMISSARY OWNEMPERATOR <br /> Commissary Name C C/4 FA# <br /> Addresls , Zp S A- -Etl l� -5rBus. Phone ) Z `�3 cl- <br /> City Zip _Owner/Operator kV\C(� , 1 \(n Q I C�� <br /> Check all appropriate services provided: <br /> Ef Wastewater disposal '0,3-compartment sink OkElectrical hook-ups <br /> Solid waste disposal 0 Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning ® Store refrigerated food )M Potable water <br /> CI Store dry food/supplies Overnight parking A Vehicle wash <br /> 1 k CI , hereby state that the information I have provided is current,true and <br /> correct to the best of my-khowledge,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+ a EHD immediately. <br /> Signature Date OS 30k` <br /> 3. To.be collfi _leted b the ENV HEALTH 'urisdiction oufside of San ,boa 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 j T 209 468-3420 1 F 209 464-0138 1 www,sjgov.org/ehd <br />