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SAN J 0 A Q U ! N Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility , Caterer <br /> Complete sections ? and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by yAPPLICANT <br /> Business Name �Lic. Plate# "LL6 93TA <br /> Owner/Operator Name [01VIL4 J6 P)1 Q 1�q YS ILI C ^ <br /> Business Mailing Address f(MW e- C t— <br /> city L;lid StatW F'VZip Ck�13.Z Bus. Ph.U'll V3 Alt. Ph. 204 ISI <br /> I, y 11PI V{t' `! tte A'('1 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 penti ^ {{ <br /> Signature._... �' - / � _ Date L4 � l �� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR ] <br /> Commissary Name P6VO5 _4 \M WI �W FA# <br /> Address % _C (-+ Bus. Phone_]V Z61 Lj <br /> City Zip 0 &32. Owner/Operator C i <br /> Check all appropriate services provided; <br /> -E�Wastewater disposal 3-compartment sink Electrical hook-ups <br /> -"olid waste disposal � Food preparation Toilet and handwashing <br /> Hot& Cold water for cleaning T� Store refrigerated food 9. Potable water <br /> Store dry foodisupplies Overnight parking Vehicle wash <br /> I. Ht 11 b�,1 ft 1"V%(1LU J L 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 notify the EHD immediately <br /> Signature_ � �A � Date Ll^ ^� <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in G4AC(4r-A" �O n County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. a above checked services are available at the <br /> above commissary_- Please notify EHD if the status of their operating permit changes. <br /> REHS Signature. i'�'! �_. _ TiaDate y Z <br /> 1868 E, Hazeiton Avenue I Stockton, California 952051 T 209 468-3420 I F 209 464-0138 1 www.sjgov.org;'ehd <br /> P�?' DS'I -11C)lD <br />