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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> ����� Greurnrsi grows �,. <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 I L Cot, of�c�o�+, LLL Lic.Plate# <br /> Owner/Operator Name S,-.9 A'A rl <br /> Business Mailing Address Sia '3 c <br /> City L!valn.wk- State CN.Zip 4 Bus. Ph. 11S'-471 - 6jiol Alt. Ph. <br /> I, S c n8 to , 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,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. Q <br /> Signature Date <br /> 2. To be com leted by COMMISSARY OWNER/OPERATOR " 74 <br /> Commissary Name -Wg VjS v, 94)�av¢n FA# <br /> Address 110 P. E I SA• Bus. Phone Zlo`I <br /> City S40cykor. Zip SSloti Owner/Operator <br /> Check all appropriate services provided: <br /> 0 Wastewater disposal I3 33-compartment sink 0 Electrical hook-ups <br /> VI/Solid waste disposal 6-'Food preparation D'oilet and handwashing <br /> Hot&Cold water for cleaning 6 Store refrigerated food 0 Potable water <br /> S,ttore dry food/supplies 0 Overnight parking 0 Vehicle wash <br /> 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 ow II notify the EHD immediately. 1 <br /> Signature Date <br /> 3.,T6be 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 />