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SAN J O A Q U I N Environmental Health Department <br /> -- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections land 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 f\Wn awl'e- (7* Oqf�J Lic. Plate# SILL6q oq <br /> Owner/Operator Name DPJ\5\- ('00-FA <br /> Business Mailing Address OUT ?Mgf4 pPVF— <br /> City ���K'Ta� State GA Zipa6ZdI Bus. Ph. 11q-Z42''1II6rAlt. Ph. <br /> 9W SGL uyf-rite , 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 pen". <br /> . <br /> Signature Date <br /> i- <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name l0(hy�q is \1 ttT 7�C��CI FA# <br /> Address (.P�C"C-nrtcaft - St- Bus. Phone�2a�1� 22N -$33� <br /> City V\ Zip SZ Owner/Operator C <br /> }��P1Ck�c,[c� �'1Ct <br /> Check all appropriate services provided: <br /> Wastewater disposal iig 3-compartment sink Electrical hook-ups <br /> Solid waste disposal 0 Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food Potable water <br /> 6k <br /> Store dry food/supplies Overnight parking IA Vehicle wash <br /> I, r\IC�Ca�t�CU (_t �A ate) , 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 owner shall notify the EHD immediately. <br /> Signature 4A� Cz .. Date DLA 12,7 Z 1) <br /> 3. To be completed b o. <br /> the ENV HEALTH jurisdiction outside of San Joaquin C <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 wwvo.sjgov.orglehd <br />