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SAN JOAQUIN Environmental Health Department <br /> — COUNTY- <br /> Cjreotne55 gio"s ht^2, <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 /> o g com'fete " �AFLI" _ . . <br /> Business Name V los Lic. Plate# <br /> Owner/Operator Name _UCI+Avrg,-t. Ci VN <br /> Business Mailing Address S 1 q 1/V <br /> Cit Lb �C State_LWZip �J,cko Bus. Ph(2h) 112Alt. Ph. <br /> I, c hereby state that the above information is current, true and correct to <br /> the best of myknowledge 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 penalti <br /> Signature //L i /GC Date 12 —2 — <br /> 2` To be Completetl_by COMMISSAR` '0 ISR" O <br /> CommissaryName ( mot FA# <br /> Address_ Bus. Phon ZG%� .2.2 '/ Mel <br /> City )-o L)r Zip 5 2 56 wner/Operator I81<p&yV &&- <br /> Check all appropriate services provided: <br /> Wastewater disposal compartment sink la"E'I�ectrical hook-ups <br /> EV'Solid waste disposal �ood preparation & toilet and handwashing <br /> C�V�Hot & Cold water for cleaning tore refrigerated food 191 Potable water <br /> E'Store dry food/supplies 12Overnight parking O 'Vehicle wash <br /> I, �'OmM i1,5-my A7-jec4-1` , 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 shall notify the EHD immediately. <br /> Signature 4& A_ Date Z 1 <br /> 3. To be,com let-ed b the`ff V HEALTH "urisdicti0n' "outsideof 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.org/ehd <br />