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SAN :JOAQUIN Environmental Health Department <br /> -COUNTY—.-..-... <br /> Greatness 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 6�1,Y�? 'Ind 911aw Lic. Plate# JRK"24; <br /> Owner/Operator Name Tow <br /> Business Mailing Address ��yy 6� lk <br /> City StateCfiZip qS21Bus. Ph. 2Ol' W373' 47Ph. <br /> hereby state that the above information is current,true and correct to <br /> the best of my knowlddge and agr a 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;nd enalties. <br /> Signature -- Date db <br /> 2. To be com le ed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address �?Zj S_ fel Z.K ISL ed Bus. Phone Z±1 41 e. 3 d -3�-sj <br /> City 5 4-"k Zip `(S2 6 Owner/Operator 1y 0 Le <br /> Check all appropriate services provided: <br /> AWastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> J ❑ Hot&Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> I, IJd✓awn Z_I' , 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 notify the EHD immediately. <br /> I <br /> Signature ± � 7 7 Date '� / Z_ <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />