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SAN JOAQUIN 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 ' ff <br /> Business Name L.1 ' V\ 3��C `LC, Lic.Plate <br /> Owner/Operator Name 4'aw, t 1K. <br /> Business Mailing Address IF Dc <br /> City Tr`u" State zip 01i'J)­1 G Bus. Ph.K�k 1 `/) Alt. Ph. <br /> hereby state that the above information is current,true and correct to <br /> the best of y 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 andpe Ities./[ a <br /> Signature 141, � Date 1� � I In <br /> 2 To be compleV'by COMMISSARY OWNER/OPERATOR Q� <br /> Commissary Name_L FA# a0 2 7 <br /> Address i (D 2� 1 iN�Ar4 Bus. Phone X09 - , <br /> City�� _Zip� OOwner/Operator i�' V <br /> Check all appropriate services provided: <br /> WWastewater disposal ❑ 3-compartment sink 0 Electrical hook-ups <br /> I(Solid waste disposal ❑ Food preparation IdToilet and handwashing <br /> ❑ Hot&Cold water for cleaning [3 Store refrigerated food IIP(Potable water <br /> ❑ Store dry food/supplies Is/ <br /> Overnight parking C Vehicle wash <br /> I, �[rjrnS�_t 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 ry <br /> 3. To b com leted b the.ENV HEALTH jurisdiction outside of San Joa uin 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 2009 468-34201 F 209 464--0138 l www.sjgov.org/ehd <br /> GNIAr <br />