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SAN JOAQUIN Environmental Health Department <br /> -- C O U h,l T Y_..__.. <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 %6WY15 Tdy s Lic. Plate# X33 9 7 x t <br /> Owner/Operator Name_ _-{/9N,7- 7- S%/ygiM <br /> Business Mailing Address /yJ41aBr1?'e C/-)R <br /> City 1VX V7',4'C,4 State CA Zip 9s".;? &s. Ph. ,?694_0 5�469�)Alt. Ph. <br /> I, 7Rwx Ti—, Si?✓6/d , 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_ —�` v�y�� d r^�( Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Q 1 C IK W G 0 C e0.( 0 0-_� FA# N W � <br /> 0 <br /> Address 3I Q E . mi nrER AYL Bus. Phone '�_—q-- °xKo" A 0 s 7C <br /> City S' o T�� c,g Zip a S�� r— Ownler/Operator A m <br /> 'i • G) <br /> Check all appropriate services provided: O 3 O <br /> wastewater disposal 0 3-comp2rtment sink Electrical hook-ups m m � <br /> - -/Solid waste disposal 0 Food preparation Toilet and handwashing D ;10m <br /> LR/Hot & Cold water for cleaning (n D X <br /> Store refrigerated food Potable water m <br /> 0 Store dry food/supplies Overnight parking 01 Vehicle wash w 111 <br /> I, 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 � � _� Date Y— <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 209164-0'i 38 1 w,vw.sjgov.org/ehd <br /> P qk 1A1 ` 05,e ITL AV'f 11mao-Y 0)' 9533 <br /> -rM �(�l/P� `T6l)CIC 6d'W � R� <br /> P �. ��9-X39-$/ <br /> � /1 ` yQ�� S g1©)a - <br />