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SAN J 0 AQ U I N Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <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 /✓1/ E_5/moi ALL/ Th Lic. Plate# Y7 <br /> Owner/Operator Name 8 yAIQ AUC SRIJTos <br /> Business Mailing Address to S CA R RD L L A UE, <br /> City STOcK7-6td; State cA Zip 'SAC(_ Bus. Alt. Ph. <br /> I, (j i)2 Cf� ENS SR Aj C S , 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 /> SignatureLr 4/: % f/ Date 2- Z 2 - Z / <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName u/UIOsJ COT_CcZW(-- -akClL C-60-SC-A- FA# <br /> Address-1 7 (7 5, YA)(C! CL1 57- Bus. Phone 2 c V '.) ?a }(6 <br /> CityS7-ock1591, Cd Zip 2S.ZtL Owner/Operator de l /g/w <br /> Check all appropriate services provided: <br /> p/Wastewater disposal 0/3-compartment sink M/Electrical hook-ups <br /> p"Solid waste disposal D'Food preparation fy Toilet and handwashing <br /> IH/Hot& Cold water for cleaning W Store refrigerated food M�Potable water <br /> torepdry food/splliies LI Overnight parking t�Vehicle wash <br /> I, h �T l /` t7 d 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 sjrll n ti EHQ immediately. <br /> Signature , Date .Z�2 Z/Z e-)L--l/ <br /> 3. To completed bthe 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.sigov.org/ehd <br />