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SAN.,-JOAQUIN Environmental Health Department <br /> --COUNTY— <br /> V c' iL <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. Tobe completed by APPLICANT <br /> Business Name S E/_C/y0 S Lic. Plate# ' 'RVQ 72-3 <br /> Owner/Operator Name .6fit/ffl iYl'c-6Cfl E t. D�iN (C k�� .S Ei'i71liL'lC A/(IGi�ifl��� <br /> Business Mailing Address S'�N2 FOK C QccK I)k, <br /> CitySh/cit?>vi StateCfzip ` :2/ b Bus. Pt( O)956- 701 Alt. Ph. <br /> I, Gir?C�v1jZp nc t7 C) , hereby state that the above information is current,true and correct to <br /> the best of rry 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 "';: Date 512ti Zu? I <br /> 2. To be com leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name WV01 6C, ( /L C c,-;TErb FA# c <br /> Address T / l l S. w( (yes ST Bus. Phon6:;?C5� <br /> City'5SbcxE2 C-6 zip ' 6 � OwnedOperator /�97_ 2(kld c <br /> Check all appropriate services provided: <br /> , *astewater disposal U3-compartment sink 31'Electrical hook-ups <br /> Solid waste disposal 0-"Food preparation E1 Toilet and handwashing <br /> Hot& Cold water for cleaning Store refrigerated food t�Potable water <br /> Ef�Store dry food/supplies 0 Overnight parking l Vehicle wash <br /> �/, 7 ) <br /> I, �1� l hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the Califomia 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 /> commissaryownn, shall nobythHD immediately. <br /> Signature �v� Datey/ -//a f <br /> 3. To be 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 IF 209 464-0138 1 www.sjgov.org/ehd <br />