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SAN :.J0AQUIN p <br /> Environmental Health Department <br /> COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility <� Caterer <br /> Complete sections 9 and 2. if your commissary is located outside of San Joaquin County also complete section I <br /> �r dM"PPLICANT <br /> Business Name r" k r t c =� ,i.t ecn4 Lic. Plate# <br /> Owner/Operator Name C, r e' Nk ' y tit <br /> Business Mailing Address 1 '1.C; L <br /> Cit Stated Zip cIS&O-5 Bus. Ph. CLi. Sc•`f Alt. Ph. <br /> I, , ._ , 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 /> ," � <br /> Signature J6,�M ,c. i r�, r n C', _ Date .s - <br /> A'i° d`b GO'MMISSARY OWIVERICPERATORN'� <br /> Commissary Name L L- <br /> r o rY , r..0 ,�� I FA# <br /> Address 2% 4r c r A Bus. Phone "Loc, 7 Z3 <br /> City StC,0c k-0-4� Zip ` 5" Owner/Operator K1 : C 1i d it - :f <br /> Check all appropriate services provided: <br /> Wastewater disposal . 3-compartment sink '� Electrical hank-ups <br /> 12( Solid waste disposal 0 Food preparation Toilet and handwashing <br /> EXHot & Cold water for cleaning 0 Store refrigerated food JR• Potable water <br /> 0 Store dry food/supplies Ar Overnight parking YkVehicle wash <br /> , 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 shai notify the EHD immediately. <br /> Signature Date <br /> < he E-NV HEALTH 'urisdi�ctio:n`:outside of San. .... a tairrCO <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 l T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br /> 1?Q2c�off`-(-- <br />