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•� h <br /> SAN .. .J OAQ U f N Environmental Health Department <br /> Lr9r COUNTY <br /> Greotness �:nw5 <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 fby APPLICANT <br /> Business Namer ([ <br /> �17G� Q-� �'�o�r1 Lic. Plate# y WS 61Z3 <br /> Owner/Operator Name _ CAVI Lc rA v,_c. 1� e- 2— <br /> Business Mailing Address �n E �ct�r�uf S <br /> City S t1 �Sgtate � Zip S 4 Bus. Ph. j0�1_ 502_'�3 ZS Alt. Ph,?0q--3 jQ TSg5( <br /> I, M ail be( AR f n Q �- 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, 2 _ �7 <br /> Signature_ et f j W A . _- Date OS r 2- J` Cr <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name C,0ANMj <br /> (>-1L j FA# <br /> Address � frS ,ke Bus. Phone zo i ' t�• Z <br /> City i-COCA , Zip C Owner/Operator�A l t,)ct+6 Akc&q�LP_'� <br /> Check all appropriate services provided: <br /> wastewater disposal Pl(3-compartment sink Electrical hook-ups <br /> olid waste disposal 13 Food preparation Toilet and handwashing <br /> of & Cold water for cleaning [3 Store refrigerated food Potable water <br /> Store dry food/supplies ?N Dvernight parking Vehicle wash <br /> I, (.AJC , hereby state that the information I have provided is current, true and <br /> correct to the b t of my kno ledge, 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 D immediately. <br /> Signature Date - 7-�� 47- <br /> 3. To be coMpfeted 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br /> PR 2c-.,oC)uy �- <br />