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S A N J O A Q U I N Environmental Health Department <br /> . � <br /> -COUN Y -- <br /> `.'' Grerwrriess 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. To be completed by APPLICANT <br /> /��, <br /> Business Name '� '1IltL 0'w- <br /> Lic. Plate <br /> Owner/Operator Name boO CjnUY-Sct <br /> Business Mailing Address IZYC Paw -i'I ,¢- <br /> City S Statee* Zipq5---�Of- Bus. Ph. ?��' b�/24�A1t. Ph. <br /> I, lz,P.o , 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 p nalties. <br /> Signature � Date a!Fs--( 1-3 Z'3 zy <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name %oa:O )Iky'k rl"- r FA# <br /> Address SSG/ 9111y4S 5ke '025 Bus. Phone g161 <br /> City �Q�/q{�J►Qy� Zip 95�Z8 Owner/Operator YL;50' r� <br /> Check all appropriate services provided: <br /> Wastewater disposal 0'-3-compartment sink "Electrical hook-ups <br /> Kj"Solid waste disposal .0'Food preparation - --Toilet and handwashing <br /> -171'Hot & Cold water for cleaning tore refrigerated food potable water <br /> ."Store dry food/supplies Il Overnight parking M Vehicle wash <br /> I• ° )Iztov oy-Lk S4� , 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 wne shall notify the EHD immediately. <br /> Signature Date b`s lu-i <br /> T <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 /> Date S <br /> y, . <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />