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-7 5cF-T <br /> SAN JOAQUIN Environmental Health Department <br /> ouNfTv <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections f and 2 if your commissary is located outside of San Joaquin County also complete section 3.- <br /> f. <br /> :f. To be completed by APPLICANT —71 <br /> Business Name 46 (� 13t A [)t� Lic. Plate# 71q A q 5.3 7 <br /> Owner/Operator NameLj-jqYt) Z U LE 15A tFlax&1,4 lij D C 2— <br /> Business Mailing Address 3WY .- Sc <br /> Ciiy51 r©ckTan] State CA5z&1= Bus. Ph. Alt. Pn ©0 CJ <br /> I, C`CCk'j f�iCl YY( > _, 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 alties / <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryNamea /U2( CI��R)A,fG Ruck lel ?A# <br /> 7 <br /> Address t [ ( 7 S. a*(&L' ST. Bus. Phon -6-E06 <br /> City SOI 4 LAzip Q5�2 D 6, Owner/Operator x 0 <br /> Check all appropriate services provided: <br /> q/Wastewater disposal OR/33-compartment sink EVEElectrical hook-ups <br /> .mow Solid waste disposal Ul"F-ood preparation Pm"Toilet and handwashing <br /> C of&Cold water for cleaning Lu.,/Store refrigerated food 51Potable water <br /> z Store dry food/supplies LY Overnight parking v ehicle wash <br /> I, 1 <br /> 1<'Joko v 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 compY with the conditions of this agreement, or if-this agreement is modified or cancelled, the <br /> commissary owner ll o ify th EHD imVrediately. <br /> Signature /A�/ Date <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 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 wvvw.sjgov.org/ehd <br /> i <br />