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SAN J OA O U I N Environmental Health Department <br /> COUNTY— <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 ( IKnl6 Lic. Plate# <br /> Owner/Operator Name j o L J E 6 g DA H I <br /> Business Mailing Address g_5SS SOUTJ6c)i=L L /'L <br /> City-N A State CF Zip `'53� ; Bus. Ph(Ao`i) 3J$ C516 It. Ph1 /e) $$i -Yy43 <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 /> Signatu / I c Date �/3 I o L` <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName V k (O KL 1}TEf2l 111 G _rbCK LQ�rel�FA# <br /> Address 17/ 7 5 . tl/V/loAi� - r Bus. Phone0t,g) "29'y-.5y/&l <br /> City ST C<'(� Cff Zip x.5,2 U C. Owner/Operator IQT 1�10 D 6 <br /> Check all appropriate services provided: <br /> Ey Wastewater disposal 0/3-compartment sink Electrical hook-ups <br /> EI/Solid waste disposal L/Food preparation El"Toilet and handwashing <br /> 113 Hot & Cold water for cleaning Store refrigerated food Potable water <br /> D/Store dry food/supplies 19"Overnight parking Cd/Vehicle wash <br /> p � <br /> k7_ -71 06 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 /> /, - - t'/3/42 L <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 www.sjgov.org/ehd <br />