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SAN.JUAQUIN Environmental Health Departmelrlt <br /> ^t 1 N i tsuntsny <br /> Olin <br /> `41ry <br /> 145 KiUoy" <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility+ Caterer <br /> Corr?plcrc sr.'rions ?and 2. if year ramntissary r.;!pealed otetsrda of San.loagelin County also complete Section I <br /> 1. To be completed by APPLICANT_ <br /> oc.Plate#_q_I.�. <br /> Business Name/ipr+ ��`'- L <br /> Owner/Operator Name �''tG✓�K_! i2..5 '`� �s- ' <br /> Business Mailing Address -f L Q <br /> �� p57� (^f ! Alt.Ph. <br /> City i v�✓b�>7 State /� zi L 7 Bus. Ph.(2.p�)�>7�` <br /> ' ,q A li, ,hereby state that the above information is current,true and correct to <br /> the best or my knowle e and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (I=HD) 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 F <br /> revocation and penalties. �/ - vat <br /> Signature—K�Lt. A. _t' !L�— - Date •.L„— 22� <br /> 2. , be completed by COMMISSARY. OWNERIOPERATOR -V , <br /> Commissary Name D 11 Vl e�t)" <br /> Address !y5 �t r Bus. Phone <br /> City ✓ I D C.fhOwnerlOperator -+'j"'`C, <br /> Check all appropriate services provided: <br /> ,Ef3-corn artment sink Electrical hook-ups 7 <br /> Wastewater disposal p <br /> p'Solid waste disposal 0'Food preparation WToiiet and handwashing <br /> PrHot & Cold water for cleaning Store refrigerated food ePotable water <br /> Store dry food/supplies Er Overnight parking of Vehicle wash <br /> t r ,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 steall notif immediately. <br /> Date 3 r <br /> Signature <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 Signato Date l2 'Zo2S <br /> 1868 E. Hazelton Avenue i Stockton, Califomia 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.orglehd <br />