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c SAN 10AQUIN a <br /> Environmental Health Department <br /> !� COU NTY <br /> Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ® Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT / <br /> � <br /> 2 <br /> Business Name U ! T Lic. Plate# `'-� f ' r n � v� <br /> Owner/Operator NameAN A !�V N 1 6 N S� l� � <br /> Business Mailing Address 9 9 it C 1,A 0 T) <br /> / P U C1 S?6) LP <br /> City52(K-fbN State CA i Bus. Ph.(2b 112_Z-5Gfl It. 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 permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocationa4ties. <br /> Signature )) Date <br /> r <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name W b NC.P t rLl N i.� TIS UCS C IIN W- <br /> Address on U m b N S I Bus. Phoned W ) 1W _ 5Q1 (D <br /> City sTP �- td Zip q S^LOOwner/Operator S I" f ENE fl 19-A D6 <br /> Check all appropriate services provided: <br /> p Wastewater disposal 13 3-compartment sink 0 Electrical hook-ups <br /> p Solid waste disposal [3 Food preparation 13 Toilet and handwashing <br /> O Hot & Cold water for cleaning 0 Store refrigerated food E3 Potable water <br /> p Store dry foo/d, Is <br /> E3 Overnight parking [3 Vehicle wash <br /> I, Y P,S iK1 'J 6§alj , hereby state that the information I have provided is current,true and <br /> correc 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 owner shall notify th HD immediately. nr l <br /> Signature Com= Date SAN ` 10 <br /> 3. To be completed by the 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 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> _x 0 S 30 U+ <br />