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SAN J OAQ U I N Environmental Health Department <br /> COUNTY— <br /> :,i _Nrness grows here. <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 /> -�-c:��{✓f.rYG! <br /> Business Name le-IP-e1 S Lie.Plate# y AAA al <br /> Owner/Operator Name OgA&1" Rl c» r kZu (" IA <br /> Business M'auli'ng Address 23174 S 1,3 <br /> City�jaoc State e-X Zip 95�aO&Bus. Ph. 907 198 1 t Ia Alt. Ph. ,toy $9-4- T. 5 S <br /> I, ma-jo 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 M- s144 L. x I r Date /S-6 /q <br /> —,2d. <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name Co m m L5,% q-1 &.L'//o FA# <br /> Address V1.401 ,. �a_c� + e �o Bus. Phone ZO2 `33g, Z�-7 /3 <br /> City ✓ o Ott Zip SZ <br /> -1-0 Owner/Operator A I be,r}C? I Com W a Gp <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink electrical hook-ups <br /> Solid waste disposal O Food preparation -pn roilet and handwashing <br /> Hot& Cold water for cleaning 0 Store refrigerated food 0Potable water <br /> ❑ Store dry food/supplies 9(Overnight parking Vehicle wash <br /> I, &AVenr)r6 /u Us" V t j_ , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowl (age,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 noti the EHD imr,�e�diately. <br /> Signature Date — ti ' ze Z,? <br /> 3. To be completed by the EN ALTH jurisdiction outside of San Joa 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />