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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a 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 com leted by APPLICANT <br /> Business Name 7 A C S Lic. Plate# L W -<5 n <br /> Owner/Operator Name fV o <br /> Business Mailing Address 235cl C <br /> City ►A(.,U.-_State�Zip Bus. Ph. � �I 2�, - <br /> - Alt. Ph. <br /> I, I C)r , 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 discontinue the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UL 60 k} M7L k►]Ub :JLOL� C( A J[�, FA# <br /> Address 4 ,Nl U Bus. Phone <br /> City ` —0 C Zip q-'-�0 �, Owner/Operator_ Q"?e ,tJ a Ill A iG?('1 ^_ <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink IJ Electrical hook-ups <br /> I"` Solid waste disposal 2 Food preparation Toilet and handwashing <br /> )�Hot & Cold water for cleaning Store refrigerated food Potable water <br /> I, Ire dry food/su lies Overnight parking Vehicle wash <br /> k C IN , 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 th ditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owners li immediately. { <br /> Signature Date `j 2-Z/ZL`2(--1 <br /> 3. To be completed b 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 w1Nw.sjgov.org1ehd <br /> pR2So�22� <br />