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Health Dopart <br /> SAN JAQU I N rlltl4�rl)"i : <br /> ---COUNTY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ,a Caterer <br /> Complete sections 9 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 Yu Y,l S+1At>c `cz- Lic.Plate# `7 C g 36 70 <br /> Owner/Operator Name T)A \) r11> `NM <br /> Business Mailing Address— V 0 <br /> city` WState:Zipg52QZ Bus. Ph Alt. Ph. <br /> I, �` ,V [b L;N 1� 1 , 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, hold must notify the EHD. Failure to notify this office may result in permit <br /> revocation and29:j;:7 <br /> . n' <br /> Signature J2� Date l �V <br /> 2. To be completed by COMMISSARY OWNER/OPER ATOR <br /> Commissary Name S/ DCISfoly is A A#�� � <br /> Address ��{��— IAJ�t� El� Al/P Bus. Phone 0�=4'� <br /> City ip 2_09 Owner/Operator l/tZ cJr; Cd/b i ,41 4 t ( )-4_) <br /> Check all appropriate services provided: _ <br /> EgWastewater disposal ®compartment sink Electrical hook-ups <br /> Solid waste disposal I-Food preparation toilet and handwashing <br /> 0 Not & Cold water for cleaning Oc-Store refrigerated food Mable water <br /> Ck-bTorfdry food/supplies Ueravernight parking 0 Vehicle wash <br /> I9, , 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 shall notify the EHD imme tely. f <br /> OCI(ton'g Wonde»Yuft � <br /> Signature I Cream �o / AL1 202/ <br /> /Y�if�l�r� i. '`/�L._� <br /> ' �t <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />