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S A W J OA Q U I N Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections > 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 yv\ca 'w\o , '4 c'4,L-4 LA Lic. Plate# C// �F� <br /> Owner/Operator Name_gci ti k uA Vvl1e✓ S �q r• tvleu 1 1 f <br /> Business Mailing Address 1 'V 1 <br /> City w�Y c State_`Zip -( F �f?u Bus. Ph._(,6� —y =?- 1q;r:Alt. Ph. <br /> I, , 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 Dates <br /> 2. To be completeAby COMMISSARY OWNER/OPERATOR <br /> Commissary Name_ FA# i00,2 749 ? <br /> Address ' (p,'L aL }�,�,r' p ' Bus. Phone wog <br /> CiZiq 5 F>SoOwner/Operator t}-RV.L <br /> Check all appropriate services provided: <br /> VWastewater disposal E33-compartment sink Electrical hook-ups <br /> ®J Solid waste disposal O Food preparation Toilet and handwashing <br /> ❑ Hot& Cold water for cleaning O Store refrigerated food VPPotable water <br /> ❑ Store dry food/supplies Overnight parking 15 Vehicle wash <br /> I, Sc_vr <-6- Lt _, hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledgefand 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 hall no a EHD immediately. <br /> Signature Date 7 2 <br /> 3. To b com leaf hit 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.1Hazellllon Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 4644--0138 1 www.sjgov.org/ehd <br /> re S�-lV\9M Vv�O`MOn` >C��YY�I lC ;;"O_. ' cc7Y-4 <br />