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, OV,CWIN C, <br />SAN w:JOAQUIN Environmental Health Department <br />---COUNTY-- <br />Gnzotne>s <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 /7 <br />Business Name'/J7� 6i61 Q-,ZU�t2L --y—e /J�%�` Lic.Plate# <br />Owner/Operator Name R A ymit) (1),t) C ✓'id�kl S lVt h1 "L c:-' R. <br />Business Mailing <br />City, 172)Cki-baj i State Ch Zipg-5o26( Bus. F`01 -e-") X136" 416'76 Alt. Ph. <br />I,- AJ f? Vb R, 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 penalties. i'7 r , <br />;1- <br />12. <br />?_ <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name r;i'�( 0 t % CA(,, 46 fkW 4 LC- A``iC= 2 FA#7 <br />Address_ (71`Z,5, Uklt` 7/d 51, Bus. Phone � a Y/(.' <br />City Zip Owner/Operator <br />Check all appropriate services provided: <br />[Wastewater disposal cr3�-compartment sink ❑ Electrical hook-ups <br />M Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br />❑ Hot & Cold water for cleaning ❑ Store refrigerated food G/P­otable water <br />❑ Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br />I, %" leXelk 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 ownn shall no t e%� D immediately. <br />Signature /, -4 f L l � Date 3l`Z312 <br />2 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin.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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />