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` r _SAN40ANIN Environmental Health Department <br /> COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections 1 and 2. if yourcommissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be.com leted by APPLICANT <br /> Business Name ^k, a Lic.Plate# 3-7 1 SC, L I <br /> Owner/Operator Name&dcor AcAtwel <br /> Business Mailing Address Ci?G I U PY_6 q 0r)C4 WCt,.( <br /> City si(`C,inyin State CjZip 5 OS Bus. Ph. Alt_ Ph. <br /> I, ,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 penalties. <br /> Signature ice: Dao xe;� <br /> 2.To be completed by COMMISSARY OWNER/OPERATOR .. <br /> Commissary Name LA FA# <br /> Address agm E "rAd AAM t Jaa Bus. Phone ca(A- /tL� (�61 • ��S 7o <br /> City O C{c}cv� Zip �1S 205 Owner/Operator L',n: n A C n e A± <br /> Check all appropriate services provided <br /> g�Wastewater disposal i-3-compartment sink EI trical hook-ups <br /> /olid waste disposal 13 Food preparation T "let and handwashing <br /> 0 Hot& Cold water for cleaning © Sto refrigerated food �able water <br /> Store dry food/supplies Overnight parking ;IlVehicle wash <br /> 1, c t'`v1(G I oQ t/i'o S . hereby state that the information I have provided is current,true and <br /> correct to the bes o 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 owne all no fy taD immediately. .. <br /> Signatu AU Date OrM 111 9LO90 <br /> 3. To <br /> 41A' mojoted 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 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov_orglehd <br />