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S A N J O A Q U NDepartment <br /> . p <br /> Environmental Health De artment <br /> ." L .n {, COUNTY <br /> Gr•eotness grows 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 M e Q Ct C S Lic.Plate# Lj y p 53 z3_ <br /> Owner/Operator Name ale✓ <br /> Business Mailing Address <br /> State zip C US Bus. Ph.2q�—7/S21103 Alt. Ph. <br /> I,_EIj\j LVA"3 C yv z_ 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, th ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe ies. -4 ` <br /> Signature Date �/ �Z Z <br /> 2. To-be completed by COMMISSARY OVIlNER/OPER.ATOR <br /> Commissary Name 0.0 t4\\&_-0(LA FA# <br /> Address 0 C 'rC7 'c Bus. Phon ?��1 3 c,: <br /> City Lg� zip C(S-ZuQ Owner/Operator AWQ C�a- \ ci INh, C(C� <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink 'i Electrical hook-ups <br /> Solid waste disposal Y E3 Food preparation Toilet and handwashing <br /> ,,Hot & Cold water for cleaning ® Store refrigerated food Potable water <br /> ® Store dry food/supplies Overnight parking Vehicle wash <br /> Pf-�ecQ hereby state that the information I have provided is current, true and <br /> correct to the best ofYny 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 not5y the EHD immediately. <br /> 1k4 <br /> Signature A l Date to <br /> 3..To,.be cor'xi "leted.b the ENV',HEALTH�.'urisdlc�ion outsjide:of5ar� Jug"uln.�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.orgiehd <br />