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SAN MOWN Env�ranmsnW HOV'Kh oqpar�MeM <br /> .-----c a u N-1 Y--- <br /> COMMISSARY <br /> ---COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3- <br /> .completed <br /> _.com leted by APPLICANT <br /> Business Name__C(),) U 1- A Q I i [ Lic. Plate# <br /> Owner/Operator Name A KI 0 7) K9 . 5 i4lVLd j"2— <br /> Business Mailing Address 11u�0(o M A G v UL <br /> City 'At, <br /> /U State_CA Zip TcS <br /> Ph. <br /> I, M AC(n 3K_ 5&2C9&72__, 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 pe s. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UPJ +I k� CWfbeIA -7 )COCK C,KA)7f::�K FA# <br /> Address J 1.0 2) i) A 1,0 U 50 Bus. Phone r,2(����5 (0 <br /> City IOCKIC U Zip CV':� Owner/Operator AYZI -h ifaQo <br /> Check all appropriate services provided: <br /> Wastewater disposal ED] 3-compartment sink 17-1 Electrical hook-ups <br /> Solid waste disposal i1 Food preparation O Toilet and handwashing <br /> Hot & Cold water for cleaning ; Store refrigerated food iJ Potable water <br /> Store dry food/supplies C5 Overnight parking Vehicle wash <br /> I, tel -Tvivo , 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 owne sh II tify the EHD immediately. <br /> Signature Date <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 1 Stockton, California 95205 1 T 209 468-34201 IF 209 464-0138 1 www.sjgov.org/ehd <br />