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i <br /> {' SAN.JQAWN Environmental Health Department <br /> C01 , MISSARY AGREEMV ENT <br /> Mobile Food Facility * Caterer <br /> Complete sections-f 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 U I,v�+NQ Lic. Plate+7� -� 73 <br /> Owner/Operator Name 1 Gi51 `` C T <br /> Business Mailing Address 530 W . L P1 6 /q <br /> City,DkKb state <br /> ,,f&P , zv Bus. Ph. -/0 2 �3A1t. Ph. <br /> 1, &'&�2-R �)/ft)�EEy7 , 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 per ' h ber rpQ notify t D. Failure to notify this office may result in permit <br /> revocation and pen�as� - <br /> Signature Date tP/ � � Z <br /> 2. To be complei by COMMISSARY OWNER/01PERATOR <br /> Commissary Name /°�dR; C fiTA>FtV(7 -rRda 661L),71111—FA# <br /> Address 17)7 (,�fS, i 6 4 _57- Bus. Phone - 6 <br /> CitY5RKCKRN,1, ( Zip 5_,2A( , Owner/Operator dgT12P�DU <br /> Check all appropriate services provided: <br /> M Wastewater disposal [�,e3-compartment sink Electrical hook-ups <br /> olid waste disposal Food preparation :, /Potable <br /> oilet and handwashing <br /> 13sHot & Cold water for cleaning Store refrigerated food water <br /> O-Store <br /> Qdry food/su s m�Overnight parking Gr Vehicle wash <br /> 1, �! l� l 4086 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 owners ti D imme ely. <br /> Signature Date <br /> 3. To be completed-by the ENV HEALTH Jurisdiction outside of Sen 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 />