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-�- SAN 1 n A Q U I N Environmental Health Department <br /> t ice_ <br /> COU N T Y----- <br /> "-�� ` Greatness grows here. <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 APPLICANT <br /> Business Name T�4COI�> & (— 10AC CJ 1-6 C_ Lic. Plate# YU R--t7oz <br /> Owner/Operator Name f.<69(1,�CO Y. c144y&—z- <br /> Business Mailing Address 8235 W // 7-/4 S <br /> /i2/- <br /> City 2cy State�Zip��Bus. Ph( ;Zoq) �'/c/ may A- Alt. Ph. <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 per ' older must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signat Date ��/4' 3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName U Aj1010 C14&:F-2/A16 �,evac C&.yT&•Q FA# <br /> Address / 7/ 7 8- L)A)1 Aj S1 Bus. Phone (all C//(v <br /> City Zip Owner/Operator A91 T/!A0[) <br /> Check all appropriate services provided: /�f() S TUieA6 c <br /> ® Wastewater disposal D 3-compartment sink D Electrical hook-ups <br /> ® Solid waste disposal D Food preparation M Toilet and handwashing <br /> ® Hot & Cold water for cleaning D Store refrigerated food 9 Potable water <br /> D Store dry food/supplies D Overnight parking M Vehicle wash <br /> I, Ate 1 7-11g;40�� , 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 caner sh notify the EHD immediately. ` <br /> Signature Date X-/`A-20,2 3 <br /> 3. To be completed by 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />