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S A N _ J 0 A QU IN 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 3. <br /> 1. To be- completed by APPLICANT <br /> Business Name t-i ��CGZO CIS Cl--(2 _ Lic. Plate# `i V F(c C t G <br /> Owner/Operator Name Fr&-cto l%/ U rl)n-c_ <br /> Business Mailing Address 11,0000 C(.yf)br �U%f� C(12- <br /> City U-Xinrcy StateO_(�- Zip 53,30 Bus. Ph.C-SIC) c4 i S 2Z-7-L Alt. Ph. <br /> 1, PrC1LCL0 1/ r1e, 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 disc tinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and ies. <br /> Signature Date l U — ILA — ZS <br /> 2;To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L L+ 00YY-%Rrc-�`G � C C e'2p FA# <br /> Address 2-q 00 Bus. Phone Z o0 4& -- LtS 7 0 <br /> City SAVI'9-� Zip Cis 2-0 Owner/Operator 6 { 2- t' Chc " t�+-4- <br /> 19 <br /> Check all appropriate services provided: <br /> ilfWastewater disposal �-compartment sink Electrical hook-ups <br /> -Solid waste disposal i'1 Food preparation Toilet and handwashing <br /> lot & Cold water for cleaning El Store refrigerated food -4f_�'P"otable water <br /> ® Store d food/supplies Overnight parking (P?-Vehicle wash <br /> I, �v-C--C,,S_, hereby state that the information I have provided is current, true and <br /> correct he 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 shall tify the EHD immediately. <br /> Signature Date o ! 7 <br /> 3. To be completed 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 IF 209 4664-0138 1 www.sjgov,orglehd <br /> p0�''2pj0)1-9r t <br />