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S Q N „�0 AQ N Environmental Health Department <br /> --COUNTY-- � -�-��t�Q • <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 .com leted b APPLICANT <br /> V�G (� C �� Vl� 1 <br /> Business Name Lic. Plate#II <br /> Owner/Operator Name <br /> Business MailingAddress <br /> City (L State Zip q� S Bus. PhrJ��`4 `�`53u3 Alt. Ph5�b akD� <br /> U` 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 )d enal6es. // 1 <br /> Signature <br /> 1 �t �/ (,MA& Datej- IL <br /> 2022 <br /> 2. To be com leted b COMMISSARY OWNER/OPERATOR <br /> Commissary Name Lo� <br /> Address 5Jt 1 nT�C erator � <br /> Q�' UnG k �Ci'v ..� Bus. Phone <br /> city(�uVA 1,18 �_ZiP_L 6C Owner/Opmt ka C ` <br /> Check all appropriate services provided- <br /> E Wastewater disposal -compartment sink C3 Electrical hook-ups <br /> preparation Q( Solid waste disposal re <br /> Food aration ® Toilet and handwashing <br /> Ij Hot& Cold water for cleaning ® Store refrigerated food 0 Potable water <br /> L7�Store dry food/supplies O Overnight parking O Vehicle wash <br /> I, rA\.'(A(?` �` >\� , 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 tify the EHD immediately.� Date91 y <br /> Signature - <br /> 3 To be com leted b the ENV HEALTH 'urisdiction outside of San Joaquin Co. <br /> The commissary issary is located in '•� lln i �L 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. Pl asease n�if the status of their operating permit W38' <br /> as <br /> REHSSignature_ Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 .org/ehd <br />