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P � 0 3"4u-7 <br /> S A NAA Q U I N Environmental Health Department <br /> COUNTY <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 <br /> Business Name_0MA(W -W QACLL� Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address 5243 I1 I N W <br /> City <br /> l�I f_State�Zip ( Bus. Ph. iJ b 511 I Alt. Ph. q • ��-' `;j2 j <br /> I, K �i(R(1 If 1 4 I .(I ((of - , hereby state that the above information is current,true and correct to <br /> the best df 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 di ntinued, the permit holder must notify-the EHD. Failure to notify this office may result in permit <br /> revocation and enal <br /> Signatur Date <br /> �J <br /> 2. To be completqtby COMMISSARY'OWNER/OPERATOR <br /> Commissary Name �, pjlqFA# OO 4 932 <br /> Address , (p 2 OIL Aae-1 p rj Bus. Phone ,Oj - 713` ( Cil <br /> City_�� Zip -7�Owner/Operator �. V <br /> Check all appropriate services provided: / <br /> Wastewater disposal ❑ 3-compartment sink 131 Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> ❑ Hot& Cold water for cleaning ❑ Store refrigerated food P(PPotable water <br /> [3Store dry food/supplies l0"/overnight parking IV Vehicle wash <br /> 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 shall no 'f9 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br /> '5MIO 14d(yr SS i <br />