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SAN 10AQUIN Environmental Health Department <br /> COLJNI Fy <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 9 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 To"be c66i 0Eeted by APPLICANT <br /> Business Name ty%a 0tiS0,0S y- aCc� f�� ly M� �}Iu�Lic. Pkate# � ���L <br /> Owner/Operator Name o Za 5 <br /> Business Mailing Address 10 0 444. e,L� <br /> City�� r+&eX-N State C Zip G 5 Bus. Ph. Alt, Ph. 26 - (o 0-3 '4 t A� <br /> 1, 'Q-P_k C , 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. -7 <br /> Signature Rorcp 1 1-"I C'7 Date <br /> 2..To be.com leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Lq Co m P_rG; a I FA# <br /> Address 20I OD 9c,,s-} 1J Bus, Phone 2. 4 flay - �70 <br /> City_ �e4kkc� Zip S W, S Owner/Operator iR, ``Lti` ,-'++Jt2. <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink Electrical hook-ups <br /> Solid waste disposal f.1 Food preparation tq Toilet and handwashing <br /> Hot & Cold water for cleaning l:_:i Store refrigerated food fj(Potable water <br /> 0 Store dry food/supplies Overnight parking 4 Vehicle wash <br /> I, , 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 to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall otify the EHD immediately. <br /> rZ <br /> Signature 2� Date — 5 <br /> 3 To be coat leted b the ENV HEALTH 'urisdiction 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 oermit 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 /> �� �5 .Z(r, � <br />