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,G p; <br /> SANJOAQUIN Environmental Health Department <br /> ---COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> I1 <br /> Business Name_ IV ;e, vP s n r I e Say le S Lic.Plate# y Z a tl 5'9 <br /> Owner/Operator Name r vc'r 30 <br /> Business Mailing Address /70 `/er,n-Zn C <br /> City oc Kion State 1'q Zip 29G Bus. Ph.4'57- 77y 773.0 Alt. Ph. <br /> .� <br /> I, Mrc_-9 �o.,: � ,hereby state that the above information is current,true and correetto <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 /> Signature E-�"� Date <br /> C/ 2-�o2 ( <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name J?DC%<P Al l/ ����/ crc—�CQ— <br /> Address /GK 3 J E W SCA &P—Bus. Phone 2-0 <br /> City ipOwner/Operator <br /> /�Ct crLL �i� <br /> Ch7iek all appropriate services provided: <br /> &Y Was <br /> tewater disposal 1-3/3-compartment sink ■/ ectrical hook-ups <br /> C olid waste disposal ❑ Food preparation p Toilet and handwashing <br /> �1 Hot & Cold water for cleaning �YStore refrigerated food O Potable water <br /> L7 Store dry food/supplies !"Overnight parking E3 Vehicle wash <br /> I, , 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 Kall notify the EHD ' mediately. / /I <br /> Signature V-MW! `— 4 A4,I'/l— Date `� 7 "V <br /> ^'s W <br /> 3. To be completed by the ENV HE 'urisdictioIi u of San Joaquin Co. <br /> omia EW05 <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 />