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SA N J 0AQU IN Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 U SR .S .Loca S Lic. Plate# 'Ll iAj k 100 <br /> Owner/Operator Name �y l fl 1 A g j kQ s o Y? <br /> Business Mailing Address j (fib JC(A VC rl S- o 1'Z C U/c l <br /> City jnC�)j ! Q (a _State C0 Zip '51 3S, Bus. Ph. ZOQ5l�'&� Alt. Ph. <br /> I':B WJA�A� kaSaTKi) , 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 Iti <br /> Signature Date 0 3 — It <br /> ~ �O 2� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name C FA# <br /> Address Wo N , F_\ cja[ck c\n S%r- Bus. Phone <br /> City Zip Q(SZO -L Owner/Operator Oyu <br /> Check all appropriate services provided: <br /> Ej'Wastewater disposal 113�3-compartment sink ET-Electrical hook-ups <br /> [Solid waste disposal 13'Pood preparation Toilet and handwashing <br /> 13'Hot& Cold water for cleaning EF Store refrigerated food E Potable water <br /> IT—Store dry food/supplies M,Overnight parking ffi,Vehicle wash <br /> I, So�1\ So�CV�C 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 shall notify the EHD immediately. <br /> Signature <br /> Date Z ZS' L� <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 F 209 464-0138 1 www.sjgov.org/ehd <br />