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A.: SAKJOAQUIN <br /> Environmental Health Department <br /> Uthdi' COUNTY <br /> +: _ l�reotraess grrws efv. C)\)e( �5 <br /> COMMISSARY AGREEMENT hone - C'�'rr'f act. <br /> Mobile Food Facility .4� Caterer `\-e _ o k P� <br /> Complete sections land 2. if your commissary is located outside of San Joaquin Countyalso complete section 3. <br /> � C <br /> 1. To be completed by APPLICANT <br /> Business Name K7A-L E V, Lic. Plate# C/13 <br /> Owner/Operator Name } i u i e,/-,,- Z <br /> Business Mailing Address ':;� 114 <br /> IDIr <br /> City S-10MICIPJ State C4 Zip Bus. Ph. b -YJ7- 2Q1eAlt. Ph. <br /> I, C Z 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. <br /> Signature 5 f—` V <br /> _Date <br /> 2. To be COrn feted b COMMISSARY OWNERIOPERATOR <br /> Commissary Name 04i ' A/ _ Uc ­ <br /> z FA# <br /> Address ! Bus. Phone &A- 2— � y <br /> City 0 iC: 4 AJ Zip ZC) Owner/Operator C 7:ella <br /> Check all appropriate services provided: V�p�s1n i <br /> Wastewater disposal 3-compartment sink ;µ Electrical hook-ups <br /> T Solid waste disposal Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food Potable water <br /> "I Store dry food/supplies Overnight parking 'C'Vehicle wash <br /> I, 1J hereby state that the information I have provided is current, true and <br /> corre t to the best of my knowled nd meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comp) ditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owners oti he D immediately. <br /> Signature Date <br /> 3. To b eom leted 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 1 Y 209 468-3420 1 F 209 464-0138 1 w-ww-sjgov.orglehd <br />