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S N J O Q Q U I N Environmental Health Department <br /> COUNT'' <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility !f Caterer <br /> Complete sections 9 and 2. 1f your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be completed by APPLICANT <br /> Business Name rj VM Lic. Plate# iU <br /> Owner/Operator Name l}et f1kU Ai <br /> Business Mailing Address ?,( at y1+ <br /> City tf �ir'n State Zip 2d Bus, Ph. Alt. Ph. ZjCI 7 L,?Z5 <br /> 1&t�y �YIAZ,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 discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and benalties. <br /> Signature H Ckq � 6GL CA a d V,n e2 Date j l ( o 2� <br /> 2. To be.completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 6, C b Yn�e.v-6 Q,( C«r f!V'ML�kM FA# <br /> Address `2-IL00 14 4 rcl orvz, Bus. Phone 2c ci <br /> city � � _ Zip C'S`Z2_ _Owner/Operator C-t � . C�h A e;-,��� <br /> Check all appropriate services provided.- <br /> Wastewater disposal 3-compartment sink o< Electrical hook-ups <br /> CEf—Solid waste disposal D Food preparation r;K*Toilet and handwashing <br /> __(Hot & Cold water far cleaning [A Store refrigerated food Potable water <br /> [] Store dry food/supplies Fi Overnight parking Vehicle wash <br /> L;Za rQ;( hereby state that the information I have provided is current, true and <br /> correct to the best oT iiiy w­,.., 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 owners all notify the EHD immediately. <br /> Signature Date 1i <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located it 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 iDate <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 �wvw.sjgov.org/ehd <br />