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SAN J a A Q U I N Environmental Health Department <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. To be completed by APPLICANT <br /> Business Name _&-&- 15 /QJf/I/Cff� � Lic. Plate# <br /> Owner/Operator Name rR O C 1S C D P5AF-'0—' ZCY!'f u S <br /> Business Mailing Address 33 y <br /> 1J• 77WT <br /> 7 <br /> City 5 ©zkL2-- ,� State 69 Zip7pp✓��2ab Bus. P 2107 62-Z-55�FAlt. Ph. <br /> l 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,theyermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation andel penalties. ' 2 <br /> Signature r xcc ,� l Date ✓ z <br /> 2. To be completed by COMMISSARY OWNER(OPERATOR <br /> ��rui6 <br /> Commissary Name 1j All of Gtt?25K yUG 6R LV K FA# <br /> Address 17 17 5, a llzlr<i� eif 57 Bus. Phone( C 9 -2- <br /> City S ��Ll< � Zipot-S2-6,6 Owner/OperatorZeYe-44 Z) <br /> Check all appropriate services provided: <br /> , ,Wastewater disposal "-compartment sink 7atlectrical hook-ups <br /> lid wash disposal ;Food preparation `Toilet and handwashing <br /> WH'ot&Cold water for cleaning more refrigerated food :table water <br /> tore dry food/suppliestt�� Overnight parking ?Thicle wash <br /> I, -IT— �Rsr`Ttbi d , 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 own hal tify the EHD immediately. <br /> Signaturei� Date Z/.10 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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orgfehd <br />