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SAN JOAQUIN Environmental Health Department <br /> IJ- , --COUNTY— <br /> Greatness <br /> —COUNTY—Greatness 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 SIA 2 ti <br /> Business Name i of Lic.Plate# <br /> Owner/Operator Name 1,2j 4.3 / O me , <br /> Business Mailing Address 7/& -7 m (9 �( <br /> City 1 State( 4-ZipBus. Ph. Alt.U1 t/��I T Alt. Ph. <br /> I, � `�y C�J4 1 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 pe [ties. 7 <br /> Signature Date <br /> a" <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 6904'" kZkC� - FA# <br /> Address 670 S -,),AGru�rw '5+ Bus. Phone J'2d9) ZZy - FISH <br /> City bolt Zip Owner/Operator A)XIt eO.ft- <br /> Check all appropriate services provided: <br /> � <br /> p'Wastewater disposal Uk 3-compartment sink 0161ectrical hook-ups <br /> C"olid waste disposal gFFood preparation M/%Iet and handwashing <br /> Riot & Cold water for cleaning ��®� 0 <br /> Store refrigerated food L�H"P�otable water <br /> M/Store dry food/supplies UYOvernight parking Vehicle wash <br /> 1, 6`4114,Ak*-Y AZ+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 notify the EHD immediately. <br /> Signature � ,, Date !d -Z5---ZZ <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 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 />