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SAN J OAQ U I N Environmental Health Department <br /> .... Ll{ti�L 4.i lTS. 3YtilW� ��f^ <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 /> 0 <br /> Business Name aIA,;, ycz\ IiA 1Z_ Lic. Plate# <br /> Owner/Operator Name k N\ �n <br /> Business Mailing Address 3 3 1 F A Ar-{ .r�cT-1'WA <br /> City StatkA' .Zip , ' J Bus. Ph� ,� (� -kL Ph. <br /> l 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 rP I C A/ 17 e FA# <br /> Address 3 L-11 5 nrn =R fC V t Bus. Phone 0 Lc li` i L <br /> City S_--�DC4K- p Zip q,�2_0 Owner/Operator CA <br /> Check all appropriate services provided: 4 V 0 <br /> Wastewater disposal 2 3-compartment sink 0, Electrical hook-ups 0 " Z <br /> rn <br /> E3 Solid waste disposal L-' Food preparation MToilet and handwashing --I 3 O <br /> �*, Hot & Cold water for cleaning Store refrigerated food 0 Potable water ,. Z n <br /> Store dry food/supplies Overnight parking ® Vehicle wash D M n <br /> r w' hereby state that the information I have provided is current, true and0 > X <br /> correct to the best of my kn &ledge, and meets the California Health & Safety Code requirements. If the food facilit*) m D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, th 0 <br /> commissary owner shall notify the EHD immediately. <br /> Date <br /> Signature I - <br /> 3. To be completed by the ENV 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 /> W <br /> '24 W002 <br />