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SA N ) OAQ U I N Environrnantall iHaalth Department <br /> COUNTY <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 com oleted by APPLICANT <br /> Business Name J4 VV-'rC(ti e'-,-1 CCAJ r "n Lic. Plate# V L -19 7G1 <br /> Owner/Operator Name 6cy- U v u t-P-VLGt <br /> Business Mailing Address Lj 2 C, 0C'V tY1 Y-A- Vh <br /> City State_CWip_'j 5�� Bus. Ph. .26 1 -fi$"1 2-21I Alt. Ph. <br /> 1, 1ra k4E-+2 , hereby state that the above information is current, true and correct to <br /> the best of my nowledge 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 pena i G <br /> Signature Date <br /> =2. To be Completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Lco. Corne --c-fci,L co,rporoki-6Y'� FA# <br /> Address 2400 F- 4.e-a" 1u" Bus. Phone 20c' `tGC4 `fS70 <br /> City_5-kVG4.0 n Zip 4 SZO5 Owner/Operator _(}• (Z- <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink Electrical hook-ups <br /> ,LZSolid waste disposal Q Food preparation r�Toilet and handwashing <br /> JZ-Hot & Cold water for cleaning 0 Store refrigerated food 1`'Potable water <br /> C] Store dry food/supplies )4—Overnight parking C>X_Vehicle wash <br /> I, 6vt, Q +cu-n-(t j , 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 no ify the EHD immediately. Gt <br /> Signature Date <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 1 Stockton: California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov,orgr'ehd <br /> W25 L-,)Db99 <br />