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S A N ) O A Q U IN 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 /> D F6,6i I <br /> Business Name ' S -tr�'�tate# 63r 00 Z3 j y Z <br /> Owner/Operator Name rl -'a, .'5r u flee— AR06q 3LI32 <br /> Business Mailing Address 7q -7 / A� i rzfhj0w,4�Z ) <br /> City ��/L�?�pt�� StateC&Zip�Bus. Ph.Z70-063-S7-7S Alt. Ph. <br /> I, /e d' , hereby state that the above information is current,true and correct to <br /> the best of my know) 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 /> Signature_(_'-ff_�A2.', i Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name��eDc��i FA# <br /> Address 19200 Alil—Tf !7w'V O rJ Bus. Phone ZCq -7 Z7-57� <br /> city kd e-4;r c Zip q'j 2-37 Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal t 3-compartment sink ❑ Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> . Hot & Cold water for cleaning 13CStore refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> I, fE(e (�ZA L/�)RA I e l_, 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 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 />