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A N 0 Q U l N Environmental Health Department <br /> --COUNTY— <br /> r c.n,n r-s - <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ^ Caterer <br /> Complete sections f and 2. if your commissary is located outside of San Joaquin County also complete section 3- <br /> 11. To be completed by APPLICANT <br /> Business Name c d�j xv, C- (f P, t Pi,"► Lic.Plate# A 7a S 3 <br /> Owner/Operator Name T* P— J% +JA6� <br /> Business Mailing Address_ Iy�1 L /2,6X _c.TLc� 1 <br /> City// YCCrL�, State�Zip S2S_lBus. Ph. Cj6 `�3C7AIt. Ph <br /> 7 _ <br /> I, ` e-&'�L-J f,�-Q1 eI i , 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 W --JaJ-? a .L "�_s P Date [ / "Z 6 2- 1 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 6tL`cK1 G' '`� C:t �cNJ�E [cf - / 'f' � [1��,A#� i <br /> Address 1 Lj 3 0 - C v,)E06, ' Bus. Phone <br /> City 5TZ)C K701'`'' Zip -A c---, 2t' Owner/Ope #e <br /> Check all appropriate services provided: <br /> Ep1Vastewater disposal U-3--compartment sink ff-Electrical hook-ups <br /> �, Solid waste disposal 10 Food preparation Toilet and handwashing <br /> i .' Hot & Cold water for cleaning Store refrigerated food 0/1 otable water <br /> _" Sto e dry food/supplies I0-Overnight parking Q Vehicle wash <br /> L L, 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 shat otify the Esji' <br /> Signature <br /> L a lfwfa t*205 <br /> 3. To be com feted 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 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 l Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />