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SANJOAQUIN Environmental Health Department <br /> ---COU iJTY- <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', It''.,be ' leted by APPLICANT <br /> Business Name 1 rY1P�C)Q Scabor Lic. Plate# 3K4135-3 <br /> Owner/Operator Name 'p-e— c_� Y_ <br /> Business Mailing Address `-I i o o m Ltx�V_ <br /> City ' -LLQ Stated} Zip Ci5 Sal Bus. Ph.0-0ti)OS5 - 11 067 Alt. Ph. L2C`i ) <br /> hereby state that the above information is current,true and correct to <br /> the b t of my knowledge and 4ree 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 ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalti s. <br /> Signature Date <br /> , : ;;'$ bei ", m feted b COMMISSARY OWNER/OPERATOR <br /> Commissary Name LG. (r 0-ro-e-r C i Cti � FA# <br /> Address IS DO `C�1S�- !A cA vC\khc, W a' Bus. Phone CZ cG) L4(9(4--- L4S 7b <br /> City S,'Agx.k(Ac n Zip C1S c> S Owner/Operator (;+ 12— " (Vxt P " fAa"d+ -3(?- <br /> Check all appropriate services provided: <br /> Wastewater disposal I( 3-compartment sink J�Electrical hook-ups <br /> Solid waste disposal E3 Food preparation ] Toilet and handwashing <br /> 14 Hot & Cold water for cleaning ® Store refrigerated food Potable water <br /> ® tore dry food/supplies / f�Overnight parking Vehicle wash <br /> I, CJi�/Z /���✓Y /l�at 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 comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa ow`or shall notify the(,E461immediately. <br /> Signature Date 3 <br /> ff be Gem' ed by the EN�/ HEALTH jurisdiction outside of San Joa 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 />