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SAN JOAOUIN Environmental Flea tR e� r t `fe���� <br />SS A ?/ COU !TY <br />ins pf✓,-j (fjt <br />(p�N� COMMISSARY AGREEMENT <br />Mobile Food Facility o 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 <br />Business Name Agsa(dA Fovd G0mrnY Lic.Plate # <br />Owner/Operator Name 6gJO iP N <br />Business Mailing Address 29`°3 A� "`s1 cfl-a le - <br />City S'i-oc�--�D ^ StateCkZip 9.2-0 L Bus. Ph. LU9)q &1 ` f'74-0 Alt. Ph. <br />I, ia!!�' AZP a-(� `, , hereby state that the above information is current, true and correct to <br />the best of e6y 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 OWNERIOPERATOR <br />Commissary <br />0. 0,7 . 20 Z'Z <br />Phone S i b'� R S- SR --�- 6 <br />Cityl�� Lt{aRn Zip gUSUt Owner/Operator <br />Check all appropriate services provided: <br />N Wastewater disposal i&9 Electrical hook-ups <br />10 Solid waste disposal oo preparation iM Toilet and handwashing <br />Iii Hot & Cold water for cleaning Store refrigerated food o a e wa er <br />® Overnight parking ®-VehichrW sh <br />I, -RAH p mit 0') S iu h Vi 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 ner shall no ' th EHD immediately. t <br />Signature 1 i'Date 01 Q I p o' <br />3. To be com feted b 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,aTHD if the taus of their operating permit changes. <br />REHS <br />13 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 454-0138 1 www.sjgov.org/ehd <br />