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SAN Q A Q(J N Environmental Health Department <br /> --COUNTY--,- <br /> Greatness <br /> —COUNTY---Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. If your commissary is locatodW&ide of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name I ficL5 P� (uCg ITZ-, Lic. Plate# 7r8(o `176 <br /> Owner/Operator Name 'T LFaa1G15 <br /> Business Mailing Address 333 k1 7-,'71 ST <br /> CityS�l)C�(r StateClq Zip S206 Bus. PhCZ60 7/6--26/6Alt. Ph. <br /> I, Fl (hC1.5�C T W*CZ , 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 /> Signature lc� h C i�C 0 Date �- <br /> 12. <br /> To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name u 010 Al 0- &TERING I RUtK CENTCR FA# <br /> Address / 7/ 7 S, gnl(6 At 5T Bus. Phone (�z(FJ Z)-yd 5w b <br /> CityS��CKToN C 6 Zip -?,52 C 6 Owner/Operator � <br /> Check all appropriate services provided: <br /> [Wastewater disposal E3"3-compartment sink If hook-ups <br /> p�'Solid waste disposal MFood preparation 'Toilet and handwashing <br /> Cr Hot& Cold water for cleaning 13 Store refrigerated food WPPotable water <br /> 13-'Store dry food/supplies Overnight parking El"Vehicle wash <br /> 1, f�If2L 22df1I d 0 -, 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 modi ed or cancelled, the <br /> commissary ownerMnifyetEHD im ediately. _Signature � ^ /� Date J ' - >' <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 Califomia 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 />