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SAN ,JOAQUIN Environmental Health Department <br /> COUNTY <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 Lic. Plate# U f)q I gj' <br /> Owner/Operator Name ku" -, n a la-AL Noti to 1AA„Oik ,.0 r1 i) . <br /> Business Mailing Address_I y 1-A ZhO A C 11,160,.1 Asir. <br /> City Skis StatejLLZip _Bus. Ph. Alt. Ph_L0j <br /> I,�.t)I t"ri 1[F,ao 0_ , 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 CJ OC ,4�Q\ C�-c` ��y K,\j �L`.� A# <br /> Address_ D 1K) K�C�C_(X�C) _ Bus. Phone <br /> City Zip S?C:' Z Owner/Operator_ -\c kNe <br /> Check all appropriate services provided- <br /> Ovastewater disposal ��3-compartment sink electrical hook-ups <br /> Solid waste disposal [� Fiod preparation 'Toilet and handwashing <br /> D Hot & Cold water for cleaning L Store refrigerated food IT Potable water <br /> Store dry food/supplies E I-V M Tice sTi <br /> I, C,:)C\RC Ln e L , 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 notify the immediately. <br /> Signature Date <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 Lzb h l <br /> 1868 E. Hazelton Avenue � Stockton. California 95205 J T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br /> p�2csoo3L,D <br />