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A ti)OAQUIN Envirormental Health Department <br /> —COUNTY— <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--1; To be co.m00tqd.by APPLICANT <br /> Business Name ! CP-C_A Z4He. Plate# 'r7 7 / /_ -2 <br /> Owner/Operator Named = Ll M UJB <br /> Business Mailing Address R V�^ <br /> Cl StateCA-Zip � 2_ Bus. Ph.-')-6jr/(09' 816D7Alt. Ph.CZ6 <br /> L/�2_A &iL C�I UL(h4(a 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. <br /> Signature ,I ZLy',�� vn !- a Date z 1 <br /> 2: To be.com leted b COMMISSARY OWNER/OP ERATOR <br /> Commissary Name STZ�0,--bAJ S NU© 1, /FR 441 1L-L FA# <br /> Address /L1 30 C ' WE f3C-10\ A1,1E - Bus. Phon�el Z-0y' 3 /�f <br /> City t-r,cis Zip S2°S� Owner/Operator �•eLI� CkoL,( VLA Ld9�t <br /> Check all appropriate services provided: <br /> 13 Wastewater disposal 13 3-compartment sink Q Electrical hook-ups <br /> g Solid waste disposal 0 Food preparation 13 Toilet and handwashing <br /> Q Hot& Cold water for cleaning 0 Store refrigerated food CI Potable water <br /> El 4tore dry food/pupplies E3 Overnight parking M Vehicle wash <br /> +2P." •[�t!u fli , 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 ow er shall notify the EH Immediately. It- /9 • ZO2J <br /> Signature Sto " warn Date <br /> 3=To.be cont leted b the`- ' - urtsd�c#Ion outside of SanJoa 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 Signature Date <br /> 1868 E. Hazelton Avenue I Stockton,California 952051 T 209 468-34201 F 209 464-0138 1 www.sigov.org/ehd <br />