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SQA JOQQUIN Environmental Health Department <br />—COUNTY— <br />Grentness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer , <br />Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed <br />by <br />APPLICANT <br />Business Name <br />6.A <br />/1 <br />CLWI W A 99, s Idyl <br />Lic. Plate# �TF-586 <br />Owner/Operator <br />Business Mailing <br />City 66LI+la:t- State &AZip 115336 Bus. Ph.(Ph. Com) 3&9-440 <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 ;permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name CcrHlrt 5.g2jia_E12FelL FA# <br />Address 4070 6 JccC'P4�4v .sF Bus. Phone L7,09) <br />City Zip aS Z`b Owner/Operator i 1—e,4vZ✓+t_ 0&ynx-,� <br />Check all appropriate services provided <br />[2r Wastewater disposal 0'�3-compartment sink W" Electrical hook-ups <br />[3/Solid waste disposal Of ood preparation 0"Toilet and handwashing <br />VHot & Cold water for cleaning Cr6iore refrigerated food tY�P otable water <br />la/store dry food/supplies Overnight parking E3 ehicle wash <br />1, � ` ZIL-4-- , 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 Date 3 01- Z._ <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 <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 />UP, <br />