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SAN$d0A0UI N Environmental Health Department <br /> < aF ' COU NTY— <br /> Greotness [funs here- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 To be completed_by APPLICANT <br /> Business Name( l Cj,'rf L _ C Zr l [�t-�G, _ Lie. Plate# tA/b l'!Y9q <br /> Owner/Operator Name <br /> Busines Mailin Address `� voolle-y- 1)0 <br /> City State Zip Bus. Ph.61Mbq!A -r4aCt Alt. Ph.(a,m)-4 <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, the permit holder must notify the END. Failure to notify this office may result in permit <br /> revocation an penalties. I c� <br /> Signatu Date ) <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name �?pI mC5 -AUZJ SA LZS jW(_ FA# <br /> Address 36 l Z VVP l e 9- 170 Bus. Phone<W I 'D44 C l%& <br /> City. 4rs't"��?C V,-T4,rV Zip Owner/Operator (ArJ O Ai4A'6 sjk ' t. <br /> Check all appropriate services provided; <br /> p Wastewater disposal © 3-compartment sink Electrical hook-ups <br /> p Solid waste disposal �ff Food preparation [3 Toilet and handwashing <br /> 13 Hot & Cold water for cleaning tP Store refrigerated food Li Potable water <br /> Store dry food/supplies Overnight parking j © Vehicle wash <br /> I, �lb VFal�C 1. ��... 4 W �eby state thg-tthe 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 shall notify-the EHD immediately, � f <br /> Signature_ -r��..__- �- Date I� pI 1 Zd Z(,p - - <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 END if the status of their operating permit changes. <br /> REHS Signature Date _ <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 />