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SAN J OAQ U I N Environmental Health Department <br /> COUNTY— <br /> COMMISSARY AGREEMENT <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 com feted by APPLICANT /1 / <br /> Business Name �� Y���1�E �� OV Lic. Plate# y L L 6q <br /> Owner/Operator Name <br /> Business Mailing Address 0147 FNL') 'FLL 2PVF- <br /> city ����1a� State CA Zip46WI Bus. Ph. ?1� -ZUZ"y I OSS Alt. Ph. <br /> \/(4Y'� <br /> 1, \GILFdl , 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"1 <br /> Signature- <br /> Date <br /> r—v <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Namel U�Y��tS�fNTA72yeM FA# <br /> Address (920 St - Bus. Phone�205) -Z2,(4 _33 <br /> City LO Z V\ _Zip SO Owner/Operator AQP: J�cJdr� C110C4 <br /> Check all appropriate services provided: <br /> K Wastewater disposal 9 3-compartment sink 001 Electrical hook-ups <br /> t&Solid waste disposal © Food preparation Toilet and handwashing <br /> V,Hot & Cold water for cleaning ty-1 Store refrigerated food Potable water <br /> 1 <br /> Storedryfood/supplies - )K, Overnight parking Vehicle wash <br /> I, A�C)Ot�CZCO (Ih O4) , 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. 11 <br /> Signature P/J� �f Z� V_ Date IZ7 Z C7 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />