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S A N J O A Q U I N Environmental Health Department <br /> COUNTY-_ _. <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 /> D. To be completed by APPLICANT - —] <br /> Business Name_/ u;o v`l u C MC `7G Ail L- - Lic. Plate# <br /> Owner/Operator Name e t-03 6 L t L"n) l /A L OC411{ LL. <br /> Business Mailing Address, ��[ (i / t- <br /> -� c �_ <br /> City���L��O"�.' State-jCAZip cSBus. Ph,)-G 'S1C)_�S Alt. Ph. i,?Uti (;_9 ]C <br /> I, 10-_(�'�11C u:/L) ki(,0C)/')i e/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 potify the EHD. Failure to notify this office may result in permit <br /> revocation and pena es. / 1 <br /> SignatureL�`f� Date I ( C/ b Co- � <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Named L4 C riti i { U( X- (Vn c'y� FA# <br /> Address 1 I n I h Bus. Phone <br /> City 5-1cac+0761 ti Zip LO G Owner/Operator �QS I Y-eop­ 7j Y-cto U <br /> Check all appropriate services provided: <br /> p Wastewater disposal 0 3-compartment sink ® Electrical hook-ups <br /> ig Solid waste disposal i� Food preparation M Toilet and handwashing <br /> ® Hot& Cold water for cleaning 0 Store refrigerated food [;L Potable water <br /> Store dry food/sup lies 0 Overnight parking Vehicle wash <br /> I, t' (i hereby state that the information I have provided is current, true and <br /> correcdto the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the cond' ' ns of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o ner s all notify the immediately. <br /> Signature Date / C <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joagu M'`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 />