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c°�x, SAN JOAQUIN Environmental Health Department <br /> " 1 a --COUNTY-- <br /> N��" Gr-eotness 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 by APPLICANT � <br /> Business Name hQ t "V � f� Lic. Plate# YU /�!—I jj Z <br /> Owner/Operator Name ___T�AA Z V' .�A <br /> Business Mailing Address 191 � EI k IxVILA <br /> City state CA Zip q'S_Wj Bus. Ph. &)Zj'7qO_3SY�AIt. Ph. <br /> I '#M 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 pe altieS. <br /> Signature Date IL/ Z 9 2911, <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name C—Lk I I �Q r n rt��_FA# <br /> Address 2 y V U 4, . -i t i2 o t c y n Bus. Phone <br /> City t'!�O✓l Zip Ct VL D 6 Owner/operator <br /> Check all appropriate services provided: <br /> 'tf Wastewater disposal a 3-compartment sink EY Electrical hook-ups <br /> g( Solid waste disposal 19 Food preparation Toilet and handwashing <br /> Hot& Cold water for cleaning q Store refrigerated food 6( Potable water <br /> Store dry food/supplies -Q Overnight parking Vehicle wash <br /> j hereby state that the information I have provided is current, true and <br /> correct to the est 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 Date ? Z <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 95205 i T 209 468-3420 i F 209 464-0138 1 www.sjgov.org/ehd <br />