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SA QU Environmental Health Department <br /> --COUNTY---- <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 /> 1. To be completed by APPLICANT <br /> Business Name Ar CM-� & +-N-C Lic. Plate# 3 <br /> Owner/Operator Name <br /> Business Mailing Address 33�33 1E <br /> City ' C�, �State C <br /> AZipo[Sla-S Bus. Ph.Stg" ` 3-99 i Alt. Ph. <br /> I, 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 y .o <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ! L hA FA# <br /> p �^Address / Bus. Phone <br /> �C)/ � J�����a��) ��,�'Y dif <br /> City 4(j- Zip % ^� Owner/Operator Z� ��� X1/4-11i <br /> Check all appropriate services provided: <br /> JzLWastewater disposal �r- 3-compartment sink electrical hook-ups <br /> R. Solid waste disposal 0 Food preparation (&'Toilet and handwashing <br /> IC Hot & Cold water for cleaning 0 Store refrigerated food 'Potable water <br /> ® Store dry food/suppliesFI�Overnight parking Orvehicle wash <br /> I, , hereby state that the information I have provided is current, true and <br /> correctto the est of my knowledge, nd 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 not' the E imme. ' e . <br /> e � <br /> Signature Date 5_ /A <br /> 3. To be-completed b the ENV TH 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 />