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SAN JOA <br /> Q UN Environmental Health Department <br /> i�.�°i";- COUNTY-- <br /> Greotness q,0„s he, <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_(( A - bCw ��T�&0 Lic. Plate# ISL 9267 <br /> Owner/Operator Name &6AJfiRr? PAfiIl.LH URRGps <br /> Business Mailing Address 0I y7 /�AKaik Cl/F 3y <br /> City ESCSON State�6 Zip y32-J Bus. Ph.20 Y S 3 y”9387 Alt. Ph. <br /> I, 4�6)NORA PA911-4& U'AR03 , 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 ties. <br /> Signature —Date 2 2 C� <br /> 2.To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Ij-N 10 f� Cid i ER/N�6 TR6(41< ER FA# <br /> Address 1717S. G(,I hc4 577 Bus. Phone <br /> City Ste T ' �/� Zip ?S2 o 6 Owner/Operator '&& (/It��d� <br /> Check all appropriate services provided: <br /> Wastewater disposal M/3-compartment sink Electrical hook-ups <br /> Solid waste disposal W Food preparationT�ilet and handwashing <br /> G"Hot & Cold water for cleaning E Store refrigerated food Q Potable water <br /> tore dry food/supplies Overnight parking ®Vehicle wash <br /> /1�I, (ooI 9-#p 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 otif e E immediately. <br /> Signature Date 9 r3-O2-0 <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />