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SANJOAQUIN Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility c 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 comlleted b APPLICANT <br /> Business Name 1'( kk ch Nyio Lic.Plate <br /> Owner/Operator Name 1 t1� 0 kCdAfX P <br /> Business Mailing Address <br /> city`r ` _State�Zip i�Bus. Ph.3GG-��IU -�9$ . Alt. Ph.gZS' II3n <br /> l,_ n1rA,-ic, nkin, , 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. ((\ I <br /> Signature �(A' (Acf1) -Pa� Date C11 Z '1 1 ,) 3 <br /> 2. To be com I t b COMMISSARY OWNER/OPERATOR <br /> Commissary Name L FA# V O� 4Add <br /> city Lss,1'��(p 2 d■ ��r' p ' Bus. Phone �O`j - ?f'=$C1* U <br /> Clty-`,,,T1trf2�_ZIP.���:!;QOwner/Operator 5kVe_ <br /> Check all appropriate services provided: <br /> WWastewater disposal 17 3-compartment sink Electrical hook-ups <br /> p(JSolid waste disposal O Food preparation Toilet and handwashing <br /> ® Hot& Cold water for cleaning O Store refrigerated food t(Potable water <br /> 13 Store-dry food/supplies 11111/overnight parking [a Vehicle wash <br /> 1, ��—i.�lr mS 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 own all no t e EHD immediately. <br /> Signature Date 7 2 <br /> 3. To b com leted b the ENV HEALTH 'urisdiction 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br /> 25M i ) tq ) <br /> ����ss C0y6ca1ctl�Z Coca 111c(� I oCn;VA <br />