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�F� �0 2-► to � <br /> SAWMAQUIN Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 nAPPLICANT <br /> Business Name r PC Q S1\QCQ,Lic. Plate# LA LAG H ED 3 7 <br /> Owner/Operator Name Q to \ x l�C� 0­1�Go <br /> Business Mailing Address r Pr-L �C ( <br /> Cit Stat�Zip G`�S bus. Ph. JIO GlgkO-�q Ph. Gn -?�� -90c)co <br /> QX' Go <br /> I, O Q , hereby state that the above information is current,true and correct to AQ <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 /> commissal'is discontinued,the permit holder must notify-the EHD. Failure to notify this office may result in permit <br /> revocatiorfand enal ' <br /> Signature sem`. Date 1o2 <br /> t <br /> 2. To be co le ij .by COMMISSARY OWNER/OPERATOR <br /> Commissary Name_L FA# oo2-7 49 <br /> Address (O 2- 1 9.4.; -1141 rel }� _ Bus. Phone a09 - <br /> cityWk-o_T Zip 9 Owner/Operator 54- <br /> C <br /> Check all appropriate services provided: <br /> WWastewater disposal ❑ 3-compartment sink M Electrical hook-ups <br /> f(Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> ❑ Hot& Cold water for cleaning C3 Store refrigerated food 9(PPotable water <br /> ❑ Store dry food/supplies M/Overnight parking a Vehicle wash <br /> I, S16E�-,.1IIc ; _, 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 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 i T 209 468-3420 1 F 209 464-0138 i www.sjgov.org/ehd <br /> �,� ? A d(yrt,ss `T-C. S <br />