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SA N J 0 A Q U I N Environmental Health Department <br /> COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 1-0ja T Lic. Plate# <br /> Owner/Operator Name nXI,l0 V a'Z Qc' �'� 0 <br /> Business Mailing Address f'`/Lj J/V <br /> City C2 C- oP State 60Zip ,5f,0j Bus. Ph. 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 ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe ' s. <br /> Signature Date (�'J <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name ,1.I �U 1� FA# <br /> Address Z y 0 i r 7qr �- c— Bus. Phone — ��- / yg <br /> City Zip � 5?c7 6 Owner/Operator <br /> Check all appropriate services provided: <br /> II/VWastewater disposal G/3-compartment sink e(Electrical hook-ups <br /> 0/Solid waste disposal Q/Food preparation E/ oilet and handwashing <br /> H 9 ot & Cold water for cleaning :,overnight <br /> tore refrigerated food Q Potable water <br /> �/Store <br /> dry food/sup-plies parking Vehicle wash <br /> I, 1��Nc? 1G,11,�r, , hereby state that the information I have provided is current, true and <br /> correct b st 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 notify the diately. <br /> Signature ~ Date I / Z9 7 <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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> PR 2c,L_X� 1 <br />