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P.,::. . ..:.Y SANa,JOAQUINp <br /> IErsvia°one�eratal Health Department <br /> --COUNTY— <br /> Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be cornleted b APPLICANT <br /> Business Name 1 ) m On � Lic. Plate# 1 to I LI 17lD <br /> Owner/Operator Name \L CkOC AA�0 CI <br /> Business Mailing Address OWA n SV n"(\-`cel 7"Z" <br /> CityQ:t C� ,kb(� State ' Zip 01521b Bus. Ph. Alt. Ph. <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 EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date <br /> 2. To be completed by'COMMISSARY OWNERQPERATOR•. . , <br /> Commissary NamerD`n" w"Y bc'(w(I 4s�'Z-I eco FA# <br /> Address CO20 G-SO _ Bus. Phone (22!2 ZZq- 633y <br /> City L Zip 9S;2-L40 Owner/Operator kynn or�cn (—,C\no C1 <br /> Check all appropriate services provided: <br /> j Wastewater disposal Iq 3-compartment sink electrical hook-ups <br /> Solid waste disposal ® Food preparation iff Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food Potable water <br /> Store dry food/supplies Overnight parking Vehicle wash <br /> .Me)a0,6,Ca OG\nooi , 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 shall notify the EHD immediately. <br /> Signature Date Ol Z b 7,1 <br /> 3. Tobe completed by the ENV'HEALTH 'urisdicfion outside ofSanp�Joa:`uin: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, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />