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SAN JOAQUIN Environmental Health Department <br />COUNTY <br />1.11i • • eo I ; f i 4 t <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 6 Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Signature reA-0 <br />ToThe completed by APPLICANT 1111 <br />Business Name al\-/e_A-d-d) Lic. Plate # - 9,4"1E '2977 <br />Owner/Operator Name a42,11_4/ai,;/./) 47, QA-6,tet. <br />Business Mailing Address goW 5 aPooz.se, $, <br />City <br />— <br />City p i-7,.. State Ch Zip?..21) Bus. Ph..,70 /— e00-9154 Alt. Ph. <br />I, 24E0PN /NO di ave_iiik , hereby state that the above information is current, true and correct to <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocatio1 and penalties. <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Signature r-eQt5 ;no Date 0)- <br />Commissary Name L 4 Co vn-trct 0, I FA# <br />Address 2-9 00 k ck sA- lAckr o-1(..) WCU Bus. Phone ( 2_0ci (-1(1,(-1 - 4E76 <br />City lk-o c_Vd-cf-1-• Zip qs2,0 S Owner/Operator Q' ta ae...-k-4-ja <br />Check all appropriate services provided: <br />EkWastewater disposal <br /> 0(3-compartment sink <br /> gi Electrical hook-ups <br />CL Solid waste disposal <br /> <br />0 Food preparation Et Toilet and handwashing <br />RHot & Cold water for cleaning CI Store refrigerated food <br /> Potable water <br />o ore dry food/supplies eil Overnight parking 4$ Vehicle wash <br />'0,tirvic , 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 th onditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary o ner shall no e EHD imrpethately. <br />Date <br />.1111111Milk the ENV HEALTH jurisdiction outside of San Joaquin C <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 />RENS 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