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SAN JOAQUIN Environmental Health Department <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 afreke ev7 Ag cit-7L4i-c. Plate # A) 9 I &- 3 <br />Owner/Operator Name d 5d44 <br />Busine s Mailing Address r) LY-1 en e <br />( L-11- <br /> State AZip 9,5124/5 Bus. Ph90-249-S57 Alt. Ph.q/: -27d--3?7,7 <br /> , 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 p rmit older must notify the EHD. Failure to notify this office may result in permit revocation an naltie <br />Signature <br /> <br />Date <br />Commissary Name <br />Address <br />Cit <br />3- mpartment sink <br />arcl--ectrical hook-ups <br />107S re refrigerated food <br />F/ood preparation <br />Cl/Potable water <br />12/Toilet and handwashing <br />ILK/ehicle wash Overnight parking <br />-ccii er6 to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to co ply with the conditipns of this agreement, or if this agreement is modified or cancelled, the <br />commissary own all no ify the EH immed' "t <br />/1 <br />Check all appropriate services provided: <br />-4/ <br />To be completed ,by COMMISSARY OWNER/OPERATOR <br />etizt . 7Z 95 <br />-Ria2a7-29,6 vt/ <br />Aistewater disposal <br />Zip I <br />-Y2/I FA# <br />,c, Bus. Phone /1C.g.„i 7 o <br />Owner/Operator i/(0/..e.f (5)7Irtsit-3-e_ <br />Splid waste disposal <br />ta/ ot & Cold water for cleaning <br />St re dry food/supplies <br />, hereby state that the information I have provided is current, true and fae"&eA <br />Signature Date 3 Pi <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 l Stockton, California 95205 I 1 209 468-3420 F 209 464-0138 I www.sjgov.orglehd