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JAN JOAQUIN 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 `7 /K&Z PlfAJSffl rd Lic. Plate# <br /> Owner/Operator Name x4045 C D P5ye-'z' LeD;;q a S <br /> Business Mailing Address ?-?-3 1 � <br /> J. 7ST <br /> City S e)z k]'v (b State04 Zip 7✓-226 Bus. P 2'07) 622--,593yAlt. Ph. <br /> 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,pennit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation andel penalties. 2 <br /> Signature i r / � // !J�!- Date ` ✓ z <br /> 2. To be completed by COMMISSARY OWNER(OPERATOR <br /> / (a C(X t E s <br /> Commissary Name u�/0 P1/ cr/t 9 �t �R uc f� FA# <br /> Address )? 17 6, _Bus. PhoneLZLq� <br /> City S Cl�i�� G4 Zipcl 2-6A Owner/Operator��i�T 7 Zk if 0 v <br /> Check all appropriate services provided: <br /> €_SjWastewater disposal 10"i-compartment sink CJ electrical hook-ups <br /> = lid wastdisposal =,-Food preparation "'`Toilet and handwashing <br /> WF1ot& Cold water for cleaning /ore refrigerated food �.:�table water <br /> ✓tore dry food/supplies 1� �7 Overnight parking ' �hicle wash <br /> I, g 7 77OY[/ 6 , 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 v hal tify the EHD immediately. <br /> Signature Date 2— <br /> 3. <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 />