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S' A ll J 0 A Q U I N Environmental Health Department <br /> C0UI',IT <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility # Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT C <br /> Business Name 13MS dGE CkEJ9M Lic. Plate+ <br /> Owner/Operator Name -7 YAD1AGM t �U��►1 l G� <br /> Business Mailing Address 7 )2U <br /> City S4-0StateC AZip Zo Bus. Ph. Alt. Ph. <br /> R_O�V�p�y� k Q11 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 i <br /> Signature Date <br /> 2. To be Completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name <br /> Q� 4s VJO tj-tiK f tier !Ct C'gICAM FA# <br /> Address /Cf3o & w6f3E''R eyi'-pLte -Bus. Phone 2-&T <br /> City 'Mcw* Zip Oi,�-Z°S Owner/Operator V E C' �Q uLi ' LJ C'� <br /> Check all appropriate services provided: <br /> i/Wastewater disposal a 3-compartment sink 7vffe—ctrical hook-ups <br /> h�/Solid waste disposal [1' Food preparation i�,7`6ilet and handwashing <br /> " Hot & Cold water for cleaning `��tore refrigerated foods Potable water <br /> rz-_ 'Store dry food/supplies Overnight parking M Vehicle wash <br /> I le-e4A CUGtW Wv7 , 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 sh II tify the immediately. d 9/2— <br /> Signature <br /> Signature _ Date <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 209 464-0138 1 wwAv.sjgov.org/ehd <br />