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3, <br /> ¢; SAN-JDAQUINEnvironmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 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_ 6) 13P Er� Lic. Plate# 7�Z z(Jr3 7 <br /> Owner/Operator Named 0)A Z(A LEI" Me P\ILI,4�j�C-2— <br /> Business <br /> Business Mailing Address / SC <br /> City,5 roc—Tc 0i State CIlZip .5461. Bus. Ph. Alt. Ph iDT � 6 <br /> 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 allies / <br /> Signature _ � Date_U I /I z <br /> 2. To be completed by,COMMISSARY OWNER/OPERATOR <br /> —7711 <br /> Commissary Name �i�/ �� L)ttI cx4T2R)416 l'izuek FA# <br /> Address t7( -7( 7 s. /Z/ ST Bus. Phon 2 G%� Z?a -6-10 6 _ <br /> City. SOI f>N CXZip �2Gro Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal M"33-compartment sink U/16lectrical hook-ups <br /> solid waste disposal U//Food preparation M/toilet and handwashing <br /> I Hof&Cold water for cleaning gAstore refrigerated food R: Potable water <br /> E Store drV <br /> food/su ies YbSvemight parking _yVehicle wash <br /> I, dA �� /e do 40 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 comp)y with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner II o th EHD imr diately. <br /> Signature Date l'/ K/ 1�2 d Z <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 /> i <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 />