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SANJOAQUIN Environmental 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. To be completed by APPLICANT <br />r <br />Business Name�o►tJ ©� �Lic.Plate # 25815_D0, <br />Owner/Operator Name M l _ Z-7 c <br />Business Mailing Address C:_. - AV(,WV1✓ <br />City StatEQP-, Zip'3 � us. Ph. 4 t'S 5s5• 7rf 9Alt. A L� <br />I, 6I C` . L ktl 1 I;k , hereby state that the above information is curren , rue 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 o— Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name t�/t �If—��6� FA# <br />Address '0a �\• w� 11'!POUG Bus. Phone 77 '7 <br />City, oN Zip 952`02-Uwner/Operator t10�PL1<� <br />Check all appropriate services provided: <br />❑ Wastewater disposal ❑ 3 -compartment sink ❑ Electrical hook-ups <br />❑ Solid waste disposal \❑ Food preparation 13 Toilet and handwashing <br />❑ Hot & Cold water for cleaning Store refrigerated food E3Potable water <br />S�Atoredry food/su plies.` l 13 Overnight [3 Vehicle wash <br />I, f k \�'a'C l�`t, 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 //Jl_/'�� '�'\ Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San. Joa _ uih 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 />abrove 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 />