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711R 2 ` <br /> SAN JOAQUIN Environmental Health Department <br /> -- COUNTY - <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 completed by APPLICANT <br /> Business Name L_ �`. 1 �&Y\ w� _ _Lic. Plate# <br /> Owner/Operator Name 'U'A A 0\(Al <br /> Business Mailing Address qq� m\nyyeo (; <br /> City �WU�w- StateGA Zip qS 0 Bus. Ph. Alt, Ph. W9 <br /> I, L GI 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. f=ailure to notify this office may result in permit <br /> revocation and p1pnalties., , <br /> Signature date O �2`� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name t } !�i(� k) C&4 rd 1111 IC ' C 1 FA# <br /> Address_I�I 11 � � ��(� k Bus- Ph!onne_2k. l " T <br /> City �1� C{C� Zip Owner/Operator 'lS c 1 � 1 ((fty- P-; o 0 <br /> Check all appropriate services provided: <br /> in Wastewater disposal 3-compartment sink EJ Electrical hook-ups <br /> Solid waste disposal II Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning © Store refrigerated food Potable water <br /> 0 Stor. �� <br /> dry food/supplies L3 Overnight parking l/ehicle wash <br /> I, i hereby state that the information (halve provided is current, true and <br /> correctto the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br /> operator fails to comply wi e i ons of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner s oti e EH immediately. <br /> Signature Date <br /> —,y <br /> 3. To bdiadmipleted 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 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />