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City Zip T5 2t- <br />Check all appropriate services provided: <br />Address 31-11 E Mr' n/f--3 QV C. Bus. Phone `a.-- - (r(V-- <br />dAccy-, S/i Owner/Operator <br />1, <br />SAN JOAQUIN <br /> Environmental Health Department <br />—COUNTY-"- <br />Gas s 9r,uvtc he.17 <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 Po:\ Lic. Plate # Pc) <br />Owner/Operator Name H -\\(--\-c2 \n Va\q-ac.._ ‘c1\ yr\na\ <br />Business Mailing Address ,3 /1--(C.jc,c (-)d\c-\t <br />City -c--) CQN--cy(\ Statkfi Zip20,,,S Bus. Ph17/() 3 7 :-T - X5eklt. Ph. <br />, 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 Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name I c 6 iv 0 <br />-Electrical hook-ups <br />EY Toilet and handwashing <br />0 Potable water <br />0 <br /> hereby state that the information I have provided is current, true and° <br /> <br />correct to the best of my kn wledge, and meets the California Health & Safety Code requirements. If the food facilitZ m <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the° • > Ut C <br />commissary owner shall notify the EHD immediately. <br />FA# <br />01 Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />g <br />5 <br />m <br />Store dry food/supplies ,C1 Vehicle wash m <br />t_g 3-compartment sink <br />L.-1. Food preparation <br />I4-Store refrigerated food <br />ir-'Overnight parking <br />Signature , <br /> <br />Date ( — <br /> <br />3. To be 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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-34201 F 209 464-0138 I www.sjgov.org/end <br />PRZI 00T1,2.