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SA N :J O A Q U I N 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 /> ,, To be ci rri-'I:et-15 i1PPLICANT <br /> Business Name tG'-e-,ri'(1 'i-[ C(A(L,n Lic. Plate#_ 9 y L-7ci 7 j <br /> Owner/Operator Name j J Lt,n �. ihc.v-w ka n , pr l v Y"cr v1 c <br /> Business Mailing Address $ ,�v' I <br /> City jv State C r- Zip -7 Bus. Ph. Alt. Ph. (3-J#� c!f$_ -?Sid` <br /> I,—�� P �c�hvr�, p 11trC� ,, 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 permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p a ties 7 <br /> Signature Date <br /> 2 To-be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Lc,, 0()q-t2 CCic�-k CQ'<-y,ry -1'A FA# <br /> Address 2 g6 4 lr - Bus. Phone 2-0c1 L{ty t —gp�f 7b <br /> City Sct-( ,� Zip 9 S?�S Owner/Operator - fir, , ``CLt�� ' lyl-L — <br /> Check all appropriate services provided: <br /> A Wastewater disposal ;1!1�3-compartment sink Electrical hook-ups <br /> Solid waste disposal Q Food preparation 1_Toilet and handwashing <br /> 4tHot & Cold water for cleaning 0 Store refrigerated food 4( Potable water <br /> Store dry food/supplies U�-Overnight parking 13 Vehicle wash <br /> I, 4"v1-tn P�fi V(-ZV-Z,n , , 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 n ify the EHD immediately. <br /> Signature Date 2-S <br /> 3 ,To be:_cp iefed b ; the ENV HEALTH jurisdiction outside of San Joa uin 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 1= 209 464-0138 1 www.sjgov.org/ehd <br />