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SAN 10 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 /> 1 . To be completed by APPLICANT <br /> Business Name k�9C-f-A 6A 9: C-Al2 Lic. Plate# +UL �2`i 2_ <br /> Owner/Operator Name r-v IQ V A 0 D A rJ-'<:f <br /> Business Mailing Address To 40 DIV- <br /> City � Po rJ State CA Zip 3e6 Bus. Ph. q:2 S-61)k—2,1 Sg Alt. Ph. <br /> I, (�(&.y 4"dd 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 12�Sr�oz3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ,1`��� `�- - -{,�2f1 U_L FA# <br /> Address \ S i r�-� Bus. Phone(acf-1) 3-319 . '-3Q(p3 <br /> City 1�4 c>(,e- ) Zip C1S�SA Owner/Operator �_g L&j(,cvy-) 1��Y' w��Z <br /> Check all appropriate services provided: <br /> M/Wastewater disposal 13'/3-compartment sink _/Electrical hook-ups <br /> Solid waste disposal [3 Food prepDt Toilet and handwashing <br /> arat of n <br /> E3'Hot & Cold water for cleaning O Store refrigerated foody Potable water <br /> u Store d ��� Overnight parking [I vehicle wash <br /> 1;1� , herebystate 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 /> A - <br /> commissa own shall notify the EHD imnlo'diately. <br /> Signatur, Date <br /> i <br /> 3. T6"be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in I CLU ._I 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's Please notify EHD if the status of their operating permit changes. <br /> rzc-N s <br /> REHS Signature L iy Date Z/ ZZ/Zo Z3 <br /> ItCMs CirC�fCt <br /> r1n; 0.fQk�vi tti(�te d.{ C mMIsSG�✓ {��Jic b� <br /> t J; A /ice r,— Mob Ie �vd Fca.KClctri. P <br /> kf- <br /> 1868 <br /> E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> � Jrl�y. <br /> is. <br />