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S A N J O A Q U I N Environmental Health Department <br /> L�?,*�Ae`ce� <br /> EIVED <br /> COMMISSARY AGREEMENT AC z 2aI <br /> Mobile Food Facility Caterer -� <br /> a���+Gomplete sections 1 and 2. If your commissary is located outside of San Joaquin County also section 3. <br /> 1 . To be completed by APPLICANT <br /> Business Name Lic. Plate# ii uJ C-, LZ Z <br /> Owner/Operator Name c, ' MCLknil <br /> Business Mailing Address 9.o Bc, ;gyp l 4 <br /> City S R4-, .,StateLn►. Zip QSLI 3 Bus_ Ph. 2uci. -r0g- 024A. Alt. Ph. "?0"I -t09 -901 <br /> I,� 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 nd penalties. <br /> Signatur ZZ Date 3l Z j ZS <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name lqax's rkJc.�e r LLL FA# <br /> Address_�2_ I S. `4' Sh - _ Bus. Phone CZ0!!)338-3463 <br /> City /Aocles-6 Zip g5S51 Owner/Operator (Vrli'►am gerk%,-i -'t <br /> Check all appropriate services provided: <br /> or Wastewater disposal GY3-com part ment sink O Electrical hook-ups <br /> WSolid waste disposal Et'Food preparation Ef-Toilet and handwashing <br /> C"Hot & Cold water for cleaning ❑ Store refrigerated food Gk')sotable water <br /> ❑ Store dry food/supplies ❑ Overnight parking I3"V ehicle wash <br /> I, Aark Lvijr Clrig , 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 owned otify the EHD immediately. <br /> Signature Dated 3 ZIA 125 <br /> 3. To be completed by the ENV H EALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in S hls}r�3S 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 commissa:1�.�C <br /> aeotify EHD if the status of their operating permit changes. <br /> REHS Signature r 6k Date 3 )�ql'�-s <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 /> P121S CD-3 W(P <br />