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SAN J O A Q U i N Environmental tal sAeal-th Department <br /> COUNTY .. . <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s„ Caterer <br /> ;omplete sections f and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> 3usiness Name C C �� Lic.Plate# <br /> )caner/OperatorName,j10)V (RAIR -5eF& & 41VZ4 6-P /fL'i� Q ui��l%Ffltl dt <br /> 3usiness Mailing Address ,�,g$c% 'Ogo, &1C—: RC. C 7, <br /> .ity. TRAS y statec��t zip p3 7 Bus. P&LCI i� Alt. Ph. <br /> hereby state that the above information is current,true and correct to <br /> he best ofj 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 /> :ommissary is discontinued the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> evocation an p nalties. <br /> Signature ��l/C Date 3 y/2 C <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> ;ommissaryName tAry l o 0 CATE 1 KG 'IR 64C(( ��`��A# <br /> kddress 0717 S . uN(0 9J S F- Bus. PhoneC2o �1 <br /> ;ityS�UCriC�1� Zip Qj 26 ( Owner/Operator �C ( -r(Wo <br /> f ��d <br /> ;heck all appropriate services provided: <br /> d Wastewater disposal 0�3-compartment sink Electrical hook-ups <br /> x Solid waste disposal Q.j Food preparation E Toilet and handwashing <br /> ot&Cold water for cleaning Store refrigerated food Imo'" Potable water <br /> :Store dry foodplies _ B/Overnight parking Vehicle wash <br /> / ( \ � , hereby state that the information I have provided is current,true and <br /> orrect to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> perator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> ommissary ow ershal notify a EHD immediately. 312 ? <br /> ignature i�� -i Date 2—/ <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> he commissaryis located in County. The above food facility meets the <br /> ommissay requirements in California Health & Safety Code. The above checked services are available at the <br /> bove commissary. Please notify EHD if the status of their operating permit changes. <br /> EHS Signature Date <br /> 868 E. Hazelton Avenue I Stockton, California 95205 1 Ti 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> f <br /> i <br />