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SAN JOAQUIN Envlronri�enta� Health Department <br /> C0L) NTV <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 E 1 A Lic. Plate# �j +-t , y <br /> Owner/Operator Name ov-n ► �0 C� k CA - <br /> Business Mailing Address .Z 4 y FUy 5 - <br /> City 4-AoCk \-ar\ State_�,AlZip G 52O� _Bus. Ph. Alt. Ph. 2-o9 - 151- -7570 s <br /> 1 �Yn t C �'-C V Ck 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 _�,c� ��r ��_ Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Co rner-a u I r rc4-1-CT" FA# <br /> Address ')-C4 Do C- "L-�rC-14`LC, Bus. Phone 2d C1 <br /> City c�- A' Zip 9 s 2O 5 Owner/Operator Cry Q "cT <br /> Check all appropriate services provided, <br /> - -Wastewater disposal aK- ,3-compartment sink c><, .' Electrical hook-ups <br /> -Solid waste disposal i..9 Food preparation Toilet and handwashing <br /> blot & Cold water for cleaning [": Store refrigerated food '<Potable water <br /> D Store dry food/supplies Overnight parking of Vehicle wash <br /> I, , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and meets the CaVifornia 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 n tify the EHD immediately. <br /> Signature Date 9 - 13 - 2-S <br /> 3. To be com leted b 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 /> Date <br /> REHS Signature <br /> 1868 E. Hazelton Avenue I Stockton. California 95205E T 209 468-3420 1 F 209 461-0'38 i wV v", .sjgov.are ehd <br />