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SA NAAQ U I N Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> 1 <br /> Business Name �w t c�i �� Zfc\S Lic. Plate# LIM0toy <br /> Owner/Operator Name <br /> Business Mailing Address 2l 2S Cutnn.i Pant DT . <br /> City 6 a AYS O StateL.A Zip 5 3 5S Bus. Ph. (109) 9115 U? Alt. Ph. <br /> 1, , 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 Jo County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is d' ontinu , t permit holder must notify-the EHD. Failure to notify this office may result in permit <br /> revocation Pd na ie . <br /> Signature Date <br /> 2. To be com let .b COMMISSARY OWNER(OPERATOR <br /> Commissary Name L FA# aO 4 9 ?_ <br /> Address J (p 2 92r Nor• w .%j �� Bus. Phone V41 - 7l3�5sP 9(,� <br /> Cit Zi ; S: Downer/Operator f-. V <br /> Check all appropriate services provided: <br /> Id Wastewater disposal 13 3-compartment sink /Electrical hook-ups <br /> ® Solid waste disposal 0 Food preparation lye Toilet and handwashing <br /> ❑ Hot& Cold water for cleaning 13 Store refrigerated food VPPotable water <br /> ® Store dry food/supplies mr"Overnight parking p'Vehicle wash <br /> jTjj-Vj05�C (4 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 a EHD immediately. <br /> Signature Date 1ZZ7ZZ <br /> 3. To b com leted 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 /> 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 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> A <br />