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SANAOAQUIN Environmental Health Department <br /> --COUNTY-- <br /> , Greatness 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 /> Business NameT E�_L fi �1 C u L &Z Lic. Plate#Z?3SZ_ <br /> Owner/Operator Name_ hI `\2 n c 1 Z <br /> Business MailinAddress W <br /> City f State Zip 9 Bus. Ph. 4SS.S-07 � Alt. Ph. <br /> I, Koji i(A J� hereby state that the above information is current,true and correct to <br /> th be'st of my knoAedge d 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 aXrc/n- <br /> ies. _ <br /> Signature r Date l d <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary j9Zt-e-<_ FA# <br /> Address 6a eU 744 Bus. Phone Z �� aay X33 <br /> City u"o+ Zip q,57_5 Owner/Operator <br /> Check all appropriate services provided: <br /> 0-'Wastewater disposal 0-, ompartment sink __ �iectrical nook-ups <br /> olid waste disposal Good preparation �0"T��a``ifet and handwashing <br /> 0-Hot & Cold water for cleaning �'�o refrigerated food or-Potable water <br /> am ore dry food/supplies Overnight parking ®'Vehicle wash <br /> I, AftZ.¢ hereby state that the information I have provided is currant, 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 Date 7- <br /> 3. To be' completed 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 I T 209 468-3420 1 F 209 464-0138 I www.sjgov.org/ehd <br /> �j 7R2. S005SS <br />