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"-`'" SANJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> ;., , Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility t Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1, Ta be completed by APPLICANT 4. <br /> BusinessName .a 1�1ni1c,PaA (1` cL 1 Lic. Plate# <br /> Owner/Operator Name_ <br /> Business Mailing Address t{0 <br /> City 0. StaterAZip qS^3g/ Bus. Ph.7�4?LZ 6;X6 Ph. <br /> I, AA-,-c.� Q c�-\,\G l.�N`'\ ,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 an naltle <br /> Signature /c�f ��l� Date2-- <br /> -2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address Bus. Phone�7 0q 2 ZLf—833K <br /> City UICI 1 Zip 015_?_LkQ Owner/Operator ak LW GhT1 j eaq <br /> Check all appropriate services provided: <br /> Wastewater disposal W 3-compartment sink Electrical hook-ups <br /> Ilk Solid waste disposal j0 Food preparation I Toilet and handwashing <br /> Hot& Cold water for cleaning lq Store refrigerated food Potable water <br /> IX Store dry food/supplies I,$ Overnight parking )9 Vehicle wash <br /> I, Uppiswa az A-e fa , hereby state that the information I have provided is current,true and <br /> correctto the best ol(Ay 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 n i he EHD immediately. / <br /> Signature Date t0 ` <br /> the ENV HEA ictiof ou sl a of San ' <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 />