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SAN J'UAQU'IN <br /> Environmental Health Department <br /> -COUNT`. --- <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 b A PLICANT <br /> Business Name r 1/1l UC1 L Lic. Plate# <br /> Owner/Operator Name -,L xj L p Ce,eA Yin h <br /> Business Mailing Address_L L- C1 e L j n <br /> City State Zip��?Bus_ Ph._ � Alt. Ph. ���(Pq <br /> I,_ C-1 u , hereby state that the above information is current, true and correct to <br /> the best of my knowledge and agree tb 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..4 <br /> Signature ��p Ct _))i\n Y1- Date �� 2'� 2� 212 <br /> 2. To be completed by COMMISSARY OWNEMPERATOR <br /> Commissary Name 6 o (i V <br /> Address_ .L�YI �` ..__-• Bus_ P one_ q oci S- 91 Lo <br /> City_ -�►� 7l Zip ±. �Owner/Operator rz ' [� <br /> Check all appropriate services provided: v yn) ' <br /> (Wastewater disposal 3•-compartment _ <br /> p partment sink � Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning ,; Store refrigerated food Potable water <br /> Store dry food/suppf s Overnight parking Vehicle wash <br /> I, hereby state that the information I have provided is current, true and <br /> correct to the best of myIEDWIledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply thIffipconditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall n immediately. <br /> Signature Date 4 <br /> 3. To m leted by 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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 � T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br /> '11W OS'-E 023 <br />