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SAN JQAQUIN Environmental Health Department <br /> —•COU NTY-- <br /> Greotness 9,ows 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 ,50tlefD SCC I Z Lic. Plate# 135(0 1 <br /> Owner/Operator Name 50E I UWAPER 5PeW(CX pL rC(..S 6O 676 <br /> Business Mailing Address 9,38 C-66&ESTon/6 cT <br /> city R&M State6h Zip?S3E,l- Bus. Ph.?746q `f07- 70sf y Alt. Ph. <br /> 6,I, 6E �!rt 0 E I S i5Z(V(cf� 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 discontin e p it holder must no' the EHD. Failure to notify this office may result in permit <br /> revocation and pe <br /> Signature ° Date I /3l- ° 2 <br /> 2. To be compfeted b4eOMM ARY OWNER/OPERATOR <br /> Commissary Name -r R l ri16 - U c Eit125'R FA# <br /> Address l:7 / 7 S • U W(G M-/ ziT• Bus. Phone -t-IN Z 1 g- <br /> City5 kbc�KT4 4d Zip y P 0 l„ Owner/OperatorOL;%)`'E oto. 4 r TI-Rilb d <br /> Check all appropriate services provided: <br /> Wastewater disposal Mt-compartment sink MElectrical hook-ups <br /> U/Solid waste disposal Lf✓Food preparation E/Toilet and handwashing <br /> [ Hot & Cold water for cleaning Store refrigerated food L--3/PN/otable water <br /> GlSttorpe`dry- food/su pliesp� Overnight parking CY9 ehicle wash <br /> 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 /> commissaryowner hall diately. <br /> Signature Date Z6 <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 />