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SAKJOAQUIN Environmental Health Department <br /> Li COUNTY--------. <br /> Greci, ess orows herr. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility r 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 ,���J.yfG,:yT�, �r� V,-;-Ztry j�� i c� Lic. Plate# <br /> Owner/Operator Name c E E 6. <br /> Business Mailing Address 3r 47 -,, �,,,,,_tn .i <br /> Citye-1� —_State"Zip-�A Bus. Ph. 11ok! t rf j-e fQ, Ph. c�'(`��5n <br /> l 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 an penalties. / <br /> Signature L Date 4� •4!�� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ( ��. 1 r�-J'ir,s �, L => �' �SFA# <br /> Address 7- V Vc" fig: CBus. Phone <br /> City Zip C Owner/Operator <br /> Check all appropriate services provided: <br /> a—Wastewater disposal compartment sink C'Electrical hook-ups <br /> ©"'Solid waste disposal Or Food preparation E3 Toilet and handwashing <br /> 113'Hot & Cold water for cleaning 0-/Store refrigerated food U'Potable water <br /> Q Store dry food/supplies Overnight parking CYVehicle wash <br /> I, -� , '_S i, �•• hereby state that the information I have provided is current, true and <br /> correct t o the b st 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 /> 7i <br /> Signature __ ...�., - Date 7 <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 />