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SQ A Q N Environmental Health Department <br /> _._..__=G J iw T Y-- <br /> _ t r'BCtrl?SS CrrC•n 5 l'Ff?. <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 G(C6 q D 5 //0 - fJbG 81 UIJ Lic. Plate# <br /> Owner/Operator Name_7-0161THO j-611n'/ 11006R6 <br /> Business Mailing Address /4 /0 5 5 i P. 61;ox 6 �/Z <br /> City6;T66tTGt6 State C:4 Zipl��66 Bus. Ph. <br /> f <br /> I, gu �f✓ �l'9/m/ /t u C-CA(, 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 dis�inued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocationi�pd;j)enalties. / <br /> Signature Date <br /> Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName U41I.4til C N Rl/1,lG Rink CQJ-16 —FA# <br /> Address 1717 S, d1lVto� Bus. Phoneczoo �q�"�/ 6 <br /> Citys(DCKTJ/y �4 Zip Owner/Operator-r-r/R (- 016) <br /> Check all appropriate services provided: <br /> ET-Wastewater disposal U-3-compartment sink M Electrical hook-ups <br /> ®'Solid waste disposal E3"Food preparation E"Toilet and handwashing <br /> Er Hot & Cold water for cleaning a Store refrigerated food U-Potable water <br /> £?'( <br /> Store dry food/supplies l/Overnight parking E'Vehicle wash <br /> - I70&1 0&1 , 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 ownZ!�� <br /> ediately. <br /> p` Signature Date Z"?, I �j <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San 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 /> I11 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 i T 209 468-34201 F 209 464-0138 1 %,%Nvvv.sjgov.org%ehd <br />