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SAN. JOAQUIN Environmental Health Department <br /> t^= —COUNTY--- <br /> �. �a�.' Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name Nv-k'MO n ±a—ek as Lic.Plate# (OP 20 S°) I <br /> Owner/Operator Name "aqq ( VC--'b+A'1 <br /> Business Mailing Address 1MV9 etc-&Lv�- 4t6 &W <br /> City StateM ZipV--� `Bus. Ph. ,Wl Alt. Ph. <br /> I, "r)ly4V)b2 F-64-" hereby state that the above information is current,true and correct to <br /> the ti se t of m 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 per it holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p nalties. <br /> Signature Date I lid 123 <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR. <br /> Commissary Name S FA# <br /> Address l070 tsi— Bus. Phone(7 Z — 33 <br /> City l_Q'\l Zip qS2Ll0 Owner/Operator 1q <br /> Check all appropriate services provided: <br /> �( Wastewater disposal IT 3-compartment sink Electrical hook-ups <br /> Solid waste disposal (9_,Food preparation 'Toilet and handwashing <br /> i Hot & Cold water for cleaning Store refrigerated food `Potable water <br /> 19 S ore dry food/supplies Overnight parking ,Vehicle wash <br /> 1, hereby state that the information I have provided is current, true and <br /> correct to the best of m nowledge,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 no' the EHD immediately. <br /> Signature / Date I 2 <br /> 3. To be cdrfipleted 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 /> M above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> L <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 /> 4- <br />