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S A NPJ 0 A Q U N Environmental Health Department <br /> ` COUNTY <br /> .a, tow` Greetness gic—s here. <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—AC Vy►n �h tvc &iQV S Lic. Plate#--,,3 � Sg <br /> Owner/Operator Name <br /> Business Mailing Address 3.3-�':':� E IVV�ky\ -Si <br /> Cit I S-f b k,+un ._—State--CAZip ft Us Bus. Ph. 1 o" `0� -` 31 Alt. Ph. <br /> I, r",ti Q -7-vc 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 '�- <br /> 2. To be completed by COMMISSARY/OWNER/OPERATOR <br /> Commissary Name ' L FA# <br /> Address _ jr � �r ��a7St--Bus. Phone <br /> Zip Owner/Operator AAA <br /> Check all appropriate services provided. <br /> Wastewater disposal �r- 3-compartment sink electrical hook-ups <br /> Solid waste disposal ® Food preparation Toilet and handwashing <br /> FHot & Cold water for cleaning M Store refrigerated food Potable water <br /> 0 Store dry food/supplies Flovernight parking Kvehicle wash <br /> I, l ,r , hereby state that the information I have provided is current, true and <br /> correct to the 6est 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. <br /> Signature e <br /> g c pate Y - <br /> 3. To be completed_by the ENV FIZ&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,orglehd <br />