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'. SA NsJ OAQ U I N Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 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 r-6 12 1 (-ci V\ Lic. Plate# <br /> Owner/Operator Name j o,.� P*n fe f\ Q <br /> Business Mailing Address._ 2 5-3`Z- iC Po 12� <br /> City_�c_k t-t r\ Statd- --Zip SZaS Bus, Ph. Alt. Ph. 20 q— 30 q 1 <br /> e- A—YNAPInkowar-ckm �IlctyAereby 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, thj permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penaltie <br /> Signature Date 2 r 2 Ua <br /> 2. To be compl ted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ct 00 crier c-o�=A c.;r Do r-c f7" >=A4 <br /> Address 2CIM ► =- L, ,LW Bus. Phone Zaq— Y(yy--`(670 <br /> City �'T Gk Zip Q S Owner/Operator_ 6 , 1Z. "C 1�p'' { ,�G} - <br /> Check all appropriate services provided: <br /> qd Wastewater disposal cig-3-compartment sink Electrical hook-ups <br /> Solid waste disposal 0 Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning LI Store refrigerated food cR.Potable water <br /> 0 Store dry food/supplies -4-Overnight parking Q Vehicle wash <br /> I, LC' P-'GYCL104:L� 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 otify the EHD immediately. <br /> Signature Date 1— 2 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Coo <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 � F 209 464-0138 1 www,sjgov.org/ehd <br /> �2J I-4-D <br />