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SAN JOAQUIN Environmental Health Department <br /> L COUNTY <br /> Crreafncss 9, s here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> [._To be completed by APPLICANT <br /> Business Name 6 ,141 v c� <br /> l �cy�c�,1r a'\ Lic. Plate# q VA']�$� <br /> Owner/Operator Name <br /> Business Mailing Address Jona e a h Ay t <br /> City $�c cK i(? n _State_C�Zip 75,111a"�Bus. Ph. !J t-j - Qo-D,;k�aAlt. Ph.9I6 -%G")l� <br /> I, 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 rmit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and es. <br /> Signa <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name !./%y l(JA C,�CX_ me>tAA' CAFt, FA# C0 /3 q 42oz. <br /> Address 6'ZD 1�)lBus. Phone[ t* � — 6 Lf 1 Z <br /> City 5a-C:K'C1yn.en-tb Zip Owner/Operator C]o 1h CQarn eZ <br /> Check all appropriate services provided: <br /> ® Wastewater disposal 3-compartment sink Electrical hook-ups <br /> M Solid waste disposal Food preparation �9 Toilet and handwashing <br /> 933Hot & Cold water for cleaning Store refrigerated food ® Potable water <br /> Q Store dry food/supplies EP Overnight parking ® Vehicle wash <br /> I, , hereby state that the information l 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 shall notify the EHD immediately. <br /> Signature +�1 Date L j I Q, 2 <br /> 3. To be, completed h the ENV HEALTH jurisdiction outside,of SaJ.oa uin Co: <br /> The commissary is located in �jaC ice. v1�y 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 3 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />