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SAN J O A Q U I N Environmental Health Department <br /> C O U NI-T-Y_ _. <br /> 4J4 ESV <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 r! n �1 /� <br /> Business Name CQ-% fiIO f/lell-vo Lic. Plate# R <br /> Owner/Operator Name i!5 0/�s 7_o IMi 00k <br /> Business Mailing,,/Address 57'�e G (.��B/e!'r� sT— <br /> CityCdState G/t_Zip /S�66 Bus. PhJd6 31 Alt. Ph. <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 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 bCOMMISSARY <br /> /OWNER/OPERATOR <br /> Commissary Name U4110dC_I�T�F4r IV& _/F&a FA# <br /> Address �7/ 7S� aAjloti 5-F� Bus. Phone <br /> City5-1bCK-(b ; CY[ Zip SAO 6 Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 11/3-compartment sink ( Electrical hook-ups <br /> EVSolid waste disposal D Food preparation Toilet and handwashing <br /> 13/Hot & Cold water for cleaning l'-'q/Store refrigerated food �/Votable water <br /> . Stored food/su lies I„lk'Overni ht arkin — Vehicle wash <br /> rY PP 9 P g <br /> 1, hk­r ! ( R'Q(' , 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 sha i he EHD i mediately. <br /> Signature Date <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 />