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SAN JOAQUIN Environmental Health Department <br /> COUNTY--- - <br /> Gt -otness grows see , <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 /> APPLICANT <br /> Business Name ryA wn n � V G' C. Lic. Plate# <br /> Owner/Operator Name Z V -', I V-\ N4yct rQ-Z �co n <br /> Business Mailing Address Z 3 0(Q `�Ck C b n CN Y'CA L <br /> City State0"+ ip j2Zc Bus. Ph. 2�� t9 `�7 jilt. Ph. <br /> `c V e- y y� I�i�y(% r ICZ (ZO►t'her�ty-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 vironmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the permi older must notify the EHD. Failure to notify this office may result in permit <br /> revocation an p ' ties. <br /> / ell <br /> Signature ` Date 1 D I <br /> tely lE ` COMMISSARY OWNER/OPERATOR <br /> Commissary Name UC,,. Co m e CA Ck CU V FA# <br /> Address 2 a n U C • ��Yc�krc, W G w Bus. Phone 2 a 9S�6 <br /> City Sk-pC.k:A-� Zip 9 5Zo 5 Owner/Operator—&, nQ�}- <br /> Check all appropriate services provided: <br /> Wastewater disposal *3-compartment sink Electrical hook-ups <br /> Solid waste disposal O Food preparation Toilet and handwashing <br /> ,®.Hot& Cold water for cleaning 0 Store refrigerated food It Potable water <br /> 0 Store dry food/supplies Overnight parking M Vehicle wash <br /> I, ,�'ow t r-C' i— o ) , hereby state that the information I have provided is current, true and <br /> correct 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 sh notify the EHD immediately. <br /> Signature Date <br /> 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 /> p1229LQ 21 <br />