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F 2 tc) S <br />SAN ,JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />:7 • <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 0 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 />Ke, (4>j <br />Ro (A) i2(.2() Q.) <br />Business Mailing Address ,F(.621 <br />City State 011Zip 6'63 5 (-' Bus. Ph. l(C525- -3L9— <br />Lic. Plate # $2- 17 Business Name <br />Owner/Operator Name <br />23Z,k.• Alt. Ph. <br />I, <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is disSontinued, tbe ermit holder must notify-the EHD. Failure to notify this office may result in permit <br />revocation and pen ties. <br />Signature • <br />• hereby state that the above information is current, true and correct to <br /> <br />Date <br /> <br />2.10 be complet*tby COMMISSARY OWNER/OPERATOR <br />Commissary Name L,44-brpp p--;204 FA# oo 7493,2 <br />Address I (0 20,1 HA,--PsrJ Rci Bus. Phone ,20, - itte <br />RI4W)1. <br />Store dry food/supplies 113/Overnight parking aK/ehicle wash <br />ESigia , hereby state that the information I have provided is current, true and <br />correct to the best of my knowledgefand meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary own hall noltIe EHD immediately. <br />Signature <br /> <br />Date <br /> <br />d Solid waste disposal <br />Hot & Cold water for cleaning <br />City 1444 )enne Zip 9$ s3o Owner/Operator <br />Check all appropriate services provided: <br />Wastewater disposal 0 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />IF/Electrical hook-ups <br />03/Toilet and handwashing <br />LiePotable water <br />3. To b 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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />)4 ddce.s.s . . fd,i6 r/ J/ <br /> qo