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` SAN J Q A Q U I N Environmental Health Department <br /> L- %8 ----COUNTY--- <br /> ,a <br /> Greotness 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 <br /> completed by APPLICANT <br /> Business Name 7 A CO( ) VQeA ".A 0 eG Lic. Plate# <br /> Owner/Operator Name "A (',e LI/� G 0 Aj 7,46 6:--Z <br /> Business Mailing Address 131 A )A 0 NTV;e S-T <br /> Cit y 5-TU�K-1()AJ State_CL�-Zip 0'4 Bus. Ph. _20a Ph. <br /> I, M Ar,-,i A C- C 0 lU Z ALG Z , 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 /> revocationand en ies. <br /> Signature e-- Date 7 1.2 o,-)-3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name () A/10-?U (-&10 JZInIG /16tIC � <br /> Address / 7 % (/A/)0 it) 57 Bus. Phone <br /> city570-6tt rU Zip q5,-)o (, Owner/Operator 4197 7'j4W(� <br /> Check all appropriate services provided: Ala 5-704A-6 G" <br /> 0 Wastewater disposal [3 3-compartment sink El Electrical hook-ups <br /> I$ Solid waste disposal O Food preparation @ Toilet and handwashing <br /> Of Hot & Cold water for cleaning O Store refrigerated food ®' Potable water <br /> 0 Store dry food/supplies O Overnight parking ® Vehicle wash <br /> 1, A6 7 71ZAO( , 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 comp with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ner s notify the EHD immediately. <br /> Signature Date J Ct 1 .2 02- <br /> completed <br /> 2com leted b ty he 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 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br /> S <br />