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S A N :10 A Q U I N Environmental Health Department <br /> COUNT Y <br /> Greotness arc.::. her:. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 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 /> Business Name Q " r-► v Lic. Plate# C 1,;; <br /> ~} <br /> Owner/Operator Name f e Z C0 N A e fN 0 L(-) �^ <br /> Business Mailing Address 33U S = C CA &JU \J Q(N S . <br /> City 10/t) State fi'�Zip 5 2 Bus. Ph.20� 7YaAlt. Ph. <br /> 1, 1 O , 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. f <br /> Signature PPP _ Date 1 Z 1-2 To be completed by COMMISSARY <br /> �OWNER/OPERATOR <br /> r -y <br /> Commissary Name L) Iti ko kk) �. 0 ri n I t UXIC l�."r FA# <br /> Address_171 ]-1 S . U ti to+U S-1 Bus. Phone 'ZCfl- Zcj�S-- S�t rL <br /> City 5_[0[1C TU/V Zip � 5�(c Owner/Operator 1 -Ti m_ot o <br /> Check all appropriate services provided: <br /> qj Wastewater disposal 0 3-compartment sink 0 Electrical hook-ups <br /> IN Solid waste disposal 0 Food preparation Or Toilet and handwashing <br /> EX Hot & Cold water for cleaning 0 Store refrigerated food 9 Potable water <br /> 0 Store dry foodlsu lies 0 Overnight parking M Vehicle wash <br /> I, , hereby state that the information I have provided is current, true and <br /> correct o 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 noti immediately. <br /> Signature Date L k� <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 952051 T 209 468-3420 1 IF 209 464-0138 1 www.sjgov.org/ehd <br /> p�0 Sul q,5 W �- <br />