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SAN. 10AQUIN Environmental Health Department <br /> -_-COUNTY—.__.. <br /> y 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 <br /> _ted b APPLICANT /1 r� <br /> Business Name 'Ike- 6orII L -Sa f t`, Grr--i / 'Lic. Plate# ! �'S—/(4S-L <br /> Owner/Operator Name S)Q Sj (4 n 1 G1 U(2 b ICU Well, I <br /> Business Mailing Address <br /> City V h nJ-)(�-Ld ,�State�Zip 5 3 Bus. Ph. 60' I LI�-I-; 7a2��Alt. Ph. <br /> I, 0(�`;C A'/V j -VcIj'Z,L 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, a n Joa n ty Environme ealth Department (EHD) requirements. If the use of the <br /> commissary disco tin d, t perms hold t Hots the EHD. Failure to notify this office may result in permit <br /> revocation nd penalt <br /> Signature Date <br /> 2. To be com eted by COMMISSARY OWNER/OPERATOR <br /> Commissary Names)IL)i Q ly W)(ej4)C2 -W C4Z Ll 1yJT A# <br /> Address U J/l O' A_) Bus. Phoned-' <br /> City ,)�(�i('��(��1� Zips Owner/Operator ( <br /> Check all appropriate services provided: <br /> Wastewater disposal D 3-compartment sink ;' Electrical hook-ups <br /> Solid waste disposal 0 Food preparation Toilet and handwashing <br /> rte'Hot & Cold water for cleaning E3 Store refrigerated food .? Potable water <br /> Store dry food/su plies FLI Overnight parking Vehicle wash <br /> I, S i J<A hereby state that the information I have provided is current, true and <br /> corr t to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comp) a conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ow of the EHD immediately. / / <br /> Signature Date G 0/ ✓� �� �"� <br /> 3. To e completed by the ENV HEALTH jurisdiction outside of San Joaquin Go. <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 /> 'P2500 ►Lc� <br />