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SAW.JOAQUIN Environmental Health Department <br /> - <br /> ---COUNTY-Greatness grows here. <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 /> 1:76be corn leted b APPLICANT <br /> .r <br /> Business Name �"IA-k)P` /��}R"" S 0117 DWUL/r' Lic. Plate# yT>Z 6z/C33 <br /> JT <br /> Owner/Operator Name , AJ 645E <br /> Business Mailing Address (a 40 6,1y1 S 62 <br /> City Z-4rH40'2 StateGA Zip S'33013us. PhC0) 30Y-J3s0 Alt. Ph /C 301/- 7`/0-3 <br /> I, ✓k el hereby state that the above information is current,true and correct to <br /> the best f 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 pe oldernwst notify-the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. ^// <br /> Signature l/ " Date 2--3- 2-3 <br /> 2. To be corn lfet •b COMMISSARY40W.NERIOPERATOR <br /> Commissary Name_L FA# 00,7 42 3 <br /> Address ' (D a t7L! ,'14,qr ►'a rel FA - Bus. Phone .204 - 712— lit gL, <br /> City Wja'.'P Zip 953 o Owner/Operator t 2,V.t <br /> Check all appropriate services provided: <br /> 1 Wastewater disposal ❑ 3-compartment sink Electrical hook-ups <br /> ld Solid waste disposal E3 &1yFood preparation Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food [(Potable water <br /> [3Store dry food/supplies Overnight parking [S Vehicle wash <br /> 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 ' e EHD immediately. <br /> Signature Date 7 Z <br /> 3. To b .com feted b'° the ENVNEALTH 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 /> C 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> GI'��bl � c��rtSs ��i^'IiniGO ItS a' Yviail , c-rY►�1 <br />