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SAN J O A Q U# N Environmental Health ®epartmerwl�, <br /> C O U NT Y..__..__ <br /> Grec.tni <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 com leted b APPLICANT <br /> Business Name L WJA Y SOL M6 l O! M fb©b Lic. Plate# 7 (16 Y// <br /> Owner/Operator Name Tc5 US 6 AlcAF, D b �A_4/fkR <br /> Business Mailing <br /> ''s�`Address ?/.,7 ?_ L fl f� l 1' L14 <br /> City 57—oc �dUy StateC6 Zip 9SZ�6 Bus. Ph. Alt. Ph. <br /> I, 1,k5 �dU��D d P[1)0l , 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 Envirgomental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the ust notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. _ <br /> Signature _ Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name (A tit< o t< �1 4- <br /> Address 17 ( Z 5 "MO eJ ST Bus. Phone <br /> T � v <br /> City 5� LA Zip 6-4�, Owner/Operator R I (' � 'f� <br /> Check all appropriate services provided: / <br /> Wastewater disposal 3-compartment sink h/?'Electrical hook-ups <br /> ;, 2 Solid waste disposal W Food preparation Toilet and handwashing <br /> O Hot & Cold water for cleaning Store refrigerated food .:?Potable water <br /> ;:.tore dry food,/stap lies I,/Overnight parking v 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 /> commissary own Thal o D,imediately. _ <br /> Signature __� Date <br /> I 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 />