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Environmental Health Department Date Date 1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd —Lie. Plate# ^|V|^ l^l Z, Philip______________ bAN JUAUUIN -----COUNTY.-— ________Bus. Phone Owner/Operator ^aS)rg/^ ~11Y'm£c) COMMISSARY AGREEMENT Mobile Food Facility Caterer Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. |~1. To be completed by APPLICANT ~~ Business Name | 015 Q /\J \A/ H Owner/Operator Name Q (Z < Business Mailing Address | C Cft tl [V /W City Si 0QO7(J Aj state Cfr^ZipB Ph. 20^^) 9^ f y^lt. Ph. l'_—Kj—QHlflffYA hereby state that the above information is current, true and correct to — 1. ■* • * • a Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued, the permit holi revocation and penalties. Z Signature,^. 1 .-tAmiP WCrJ—Kj—OHllIflYA hereby state that the above information is current, true and correct to the best^of my knowledge and agree to utilize my approved commissary in accordance with California Health & J |er mupt notify the EHD. Failure to notify this office may result in permit Date |2. To be completed by COMMISSARY OWNER/OPERATOR | Commissary Name QKJllTM T^(/C/C fCzA/Zfc^A#_________________ ___ Address Uli 3 S~7 City ...Zip QQ-lff, Check all appropriate services provided: " Of"? Wastewater disposal 3-compartment sink & ^2) Solid waste disposal 'S(/Food preparation Hot & Cold water for cleaning O Store refrigerated food O Store dry food/supplies O Overnight parking I, \1 |ySl|C|V SoSA____,..............- correcjto the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility operator feilffio comf*—“------- ---------- — • commissary otonersh; Signature cc Electrical hook-ups J^PToilet and handwashing /Si Potable water O Vehicle wash hereby state that the information I have provided is current, true and ^wjth the conditions of this agreement, or if this agreement is modified or cancelled, the LnotrtyJhe EHD immediately. . , 3. To/^completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. The commissary is located in . . _____County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature