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4' - S A N J UAQ U I N Environmental Health Department <br /> n COUNTY <br /> Grectn¢ss yrowc hor, <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility -�. Caterer <br /> Complete sections 7 and 2. !f your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name! ,o�l_�)_ _T ,`A ( CS l_ic. Plate# E 5 C� <br /> Owner/Operator Name I.Au Ex 1­:J <br /> Business Mailing Address 1 r e 1 11l( S <br /> city � UC7d� State�Zip RSr.0 �y Bus. Ph._2oq- (,p&l- - )b 2 tAlt. Ph__2:0 (S� - 7 3&Cj <br /> 1, V 6�— lei K4,640 , 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 END. Failure to notify this office may result in permit <br /> revocation and penalties. ! <br /> Signature_' a ( TDate <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name K-) k S 1cIL I Ai G _ILZUG 0�_- Ct C,r <br /> Address�� { _ 1 5 7 Bus_ Phone <br /> Ci zipqS26 Owner/Operator 0 e <br /> Check all appropriate services provided: <br /> Wastewater disposal. 3-compartment sink IFr Electrical hook-ups <br /> Solid waste disposal Food preparation W Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food P ' Potable water <br /> Store dry food/suonlies M Overnight parking P Vehicle wash <br /> I, , hereby state that the information I have provided is current, true and <br /> correc to the best of my knowledge,and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to complyNitih the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner i he EHD immediately. ! 1 <br /> Signature Date_ _(, 1l <br /> ['-"To a completed by the ENV HEALTH jurisdiction outside of. San Joaquin Ga. <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />