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S JOADIN sp -L <br /> COUNTY <br /> TO <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 /> 1. To be completedfr b APPLICANT <br /> n <br /> Business Name 11 ,A" L �Lf"1 T1 V-f Lic. Plate# 11 V K_ �� 60 <br /> Owner/Operator Name , A��E A V A S TAP AU r) _ <br /> Business Mailing Address1_141 S PIN 6 RILL D PL <br /> city-5 Tb(Kn NfStatetk, Zip ] QBus. P - IL Ph. <br /> I,. S�rn tom. T _ _ 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 a pen alti . <br /> Signature Date <br /> 2. To be corn leted b COMnMISS�pARYrOWNERIOPERATOR <br /> Commissary Name j)N 10 N ( A-T11`' /1 v (1 TT-4169 <br /> Addressia f I V IV 6 N sT_ Bus. Phone � � 1 le--le- 51 1 to <br /> City S C - Zip s Owner/Operator "S/PfI nv r ;AA1)6 <br /> Check all appropriate services provided: <br /> Wastewater disposal X 3-compartment sink Electrical hook-ups <br /> 'Solid waste disposal X Food preparation Toilet and handwashing <br /> ? Hot& Cold water for cleaning M Store refrigerated food Potable water <br /> _iire dry food/supplies � Overnight parking Vehicle wash <br /> 1, t rQ0& '� l- Y�,'Ji� hereby state that the information I have provided is current, true and <br /> correct tb the besf of my knowledge, and meets the California Health&Safety Code requirements_ If the food facility <br /> operator fails comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commiss own r shall-notify HDimmedi tely. <br /> Signature Date O l 2b 12-192Le <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, Calromia 95205 1 T 209 468-3420 1 F 209 464-0138 1 VVWN.sjgov.org/ehd <br />