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SANsJOAQUIN p <br /> ° Environmental Health Department <br /> —COUNTY— <br /> °9 Greotness 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 comai feted 1by APPLICANT <br /> Business Name :ice. mag Lic. Plate# 6-2-T-4, 62--7 <br /> Owner/Operator Name Gt A 16 otrnp -RAI-ca <br /> Business Mailing Address to b AMe c, i <br /> Cit yStatef,& Zip Bus. Ph. d3' It. Ph. <br /> I, h IYD Gt �\ AM(d 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 /j <br /> Signature Date, �Z IJP I �20�ti <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Q\ C Y, P/ Qy c_AG19 1 FA# <br /> Address 3u(12 > iy j,, ER ff#Vl Bus. Phone <br /> City S %o c k ro/✓ Zipc,a 0( 55%o5 Own /er Operator -1 W 0 <br /> Check all appropriate services provided: n N <br /> 0 Wastewater disposal 17 3-compartment sink m-Electrical hook-ups M Z <br /> 0 Solid waste disposal O Food preparation P-Toilet and handwashing Z 3 O <br /> 0 Hot & Cold water for cleaning IrStore refrigerated food 0 Potable water n m n <br /> 0 Store dry food/supplies ®'Overnight parking 0 Vehicle wash D X n <br /> WD0 <br /> I, , hereby state that the information I have provided is current, true and (A C <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility p M D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the to <br /> commissary owner shall notify the EHD immediately. <br /> Signature Date Ja-3� —�` <br /> ;3: To be com leted b the•ENV HEALTH u.risdiction 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 />