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4UTAf. <br /> SAN 10AQUIN Environmental Health Department <br /> COU NTY-- <br /> 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. To be completed by APPLICANT <br /> Business Name �:I( Prp �jC� Lic. Plate# s 313 <br /> Owner/Operator Name r�c�V�I Ma,r-T t,e 2 TGAct� C1 <br /> Business Mailing Address <br /> City S'4'U(�� State OAZip 01 216 Bus. Ph. Wj• q22 3ta'I i Alt. Ph. �2? '3W� <br /> I, , 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 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 and penalties. <br /> Signature Date 1-90-2-S <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name uc�k�b,r1 syyb�/lt7u%'Y�u-( I LC CkCc�­" FA# <br /> Address ) `l 7O E�� �'Y' Bus. Phone (goc1�C1 3 <br /> City Zip �S Owner/Operator <br /> Check all appropriate services provided: <br /> p Wastewater disposal U-3-compartment sink C Electrical hook-ups <br /> E] Solid waste disposal E3 Food preparation Toilet and handwashing <br /> E3 Hot & Cold water for cleaning Q/Sto e refrigerated food O Potable water <br /> wi�tore dry food/supplies Ex Overnight parking ErVehicle wash <br /> I, UwU Vv--(-V-fy— , 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 n the EHD immediately. <br /> Signature Date 1'1 o <br /> 3. To be completed 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 tify 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 /> 4� <br />