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SAN _:10 A QU I N Environmental Health Department <br /> COUNTY— <br /> Greatness 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 completed by APPLICANT <br /> Business Name 0 O190i1 z_(v,/j 0A L_,VftLic. Plate#`-� � �� '7 1 <br /> Owner/Operator Name_ O til l L/3 Q AL V 6 U <br /> Business Mailing Address -3 i 50 41 A T A C.I< <br /> CityS1UQ(&/Q State A Zipei S, (,1Bus. Ph `��j �I1`;'�js (Alt. Ph. <br /> I. Ll/j j Irfg 0714( ✓A 1 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 Vad enalties. <br /> Signature �' Date L)/ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name-",)6 A,\ Cf1_ 7L_k11 G zelxk' IL-luf o <br /> Address i 7/ 1 S 1,��4.�1C�'l.rl 0 T Bus. Phone -,?(,,q- � �� ,�'-�5�`"-��,/��, <br /> City `516 I K 1C/J Zip 9 3 C) t�- Owner/Operator 0`7l oct'yl'= // ,0,o <br /> Check all appropriate services provided: <br /> Wastewater disposal Rlc,3-compartment sink ;0 Electrical hook-ups <br /> Solid waste disposal ;S Food preparation ,03 Toilet and handwashing <br /> O: Hot& Cold water for cleaning j' Store refrigerated food Potable water <br /> Store dry food/suppli 19 Overnight parking (,'Vehicle wash <br /> I, ti-s",-4 �� , hereby state that the information I/have provided is current,true and <br /> correct c the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with thg,,c9nditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shpill notifyCpEHD immediately. <br /> Signature _ Z� Date vL <br /> 3. To be com leted b 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 />