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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 /> " S Pi 'e ���-- u- PI # LPrOOZ3jyZ <br /> Business Name i`.-t1 ��I � <br /> Owner/Operator Name V-I -P, <br /> Business Mailing Address 7q -7 / 4 l re JA cu:A-�/ P <br /> City�Lejo/j� State�Zip Bus. Ph.24-0163-5715- Alt. Ph. <br /> I, ch e f-1,Q. SPG,/P d, , hereby state that the above information is current,true and correct to <br /> the best of my knowl dge 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. <br /> SignatureCA_PA-P_� 'V4Date 1—d —(�7-0 v;?-O' <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name � !1P_ <br /> Address X00 NVJ/-Tfi �IWy 87Y Bus. Phone Z()q -7 z7-5 7�11S <br /> City kd e-kr(j- Zip q5 2-3 7 Owner/Operator <br /> Check all appropriate services provided: <br /> j Wastewater disposal 1*3-compartment sink ❑ Electrical hook-ups <br /> Solid waste disposal l(Food preparation Toilet and handwashing <br /> .OHot & Cold water for cleaning Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> I, Geo tc 6-e aA LIQ JSp 7-_O,�_, 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 /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />