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SANJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness u:n':.s i <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility t 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 4U10GS _rSL8Mh Lic.Plate#3X2875 <br /> Owner/Operator Name Yt5€io(A C�STfLClj <br /> Business Mailing Address Z.66 8 10 01 AVE <br /> CitySTbC DA( State 0) Zip 95;Z61 Bus. Ph.C2091,,Ur-g0 j" Alt. Ph. <br /> I, 1 656 R)I A C�$T/L CCS ,hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree o utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San oaquin Co ty Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discon ' ied, the mit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and petes. <br /> Signature) Date <br /> 2. To e m fete by CO ISSARY OWNER/OPERATOR <br /> Commi sa Name 251eG IgUek CEft%TEP FA# <br /> Addres ( 5 . D!) S T- Bus. Phone(01) 2??-S q1 r. <br /> city_51-&-t Leto, ip .i-2 O,✓ Owner/Operatorlrr (/go4 o <br /> Check all appropriate services provided:: <br /> Wastewater disposal f 3-compartment sink 0"Electrical hook-ups <br /> 19/Solid waste disposal Ckfood preparation dToilet and handwashing <br /> M/Hot& Cold water for cleaning tore refrigerated food hr: Potable water <br /> G Store dry food/supplies [9"Overnight parking M Iehicle wash <br /> I, AJ- <br /> l ( �fT O 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 l�II n�ify thh EH immediately. -/ <br /> Signature L%W Al 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.sigov.org/ehd <br />