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�-P,aUiry cr <br /> S A N J 0 A 0 U I N Environmental Health Department <br /> -----COUNTY-- <br /> Greatness <br /> ----COUNTY-- <br /> Greatness grows here. <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 completed by APPLICANT �/ <br /> Business Name C0-t A �brV AA /1)_D Lic. Plate# 1 SL 92-67 <br /> Owner/Operator Name &61VfiRr9 Pf1101448 1111 R GAS <br /> Business Mailing Address t I y7 &K15IQ &IF )�'3y <br /> City C,5C/ 40N Staten -S3z a Bus. Ph.20 Y S 3 y-9387 Alt. Ph.Zip <br /> 1, ft oAlbkA P,1011-48 �4RM5 , 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 andties. <br /> Signature Date 21312-D 2 d <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name jkL J JO M COVer'QIA16 T�eWel< 664/7CR FA# <br /> Address 17 TS. to t c 4 ST Bus. Phone <br /> City s(rl �A Zip ,5-:2-Q $ Owner/Operator ,&r <br /> Check all appropriate services provided: <br /> ED/Wastewater disposal 12/3-compartment sink Electrical hook-ups <br /> [•/Solid waste disposal W"Food preparation �W/Tiilet <br /> and handwashing <br /> Ek'Hot & Cold water for cleaning Store refrigerated food Potable water <br /> tore dryfood/supplies d Overnight parking CO/Vehicle wash <br /> // �I ( <br /> 1, k/4,o O , 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 own shall notif e E immediately. /,? <br /> Signature Date 9 1 02-0 <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, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />