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c]VrN r <br />°� -- SAN 10AQU I N Environmental Health Department <br />L-.� COUNTY <br />`4a F 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 />Business Name. . <br />Owner/Operator Na <br />Business Mailing Ac <br />City Z4411 State 6;4Zip 9 5-37 7 Bus. Ph. ZD l 4-07 8173 Alt. Ph. z /)f, �i�1_j S CJ <br />I,ereby state that the above information is current, true and correct to <br />the best of my knowledge an gree 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 />Signatu <br />Date : 5 /.-1j,ZG <br />12. To be completed by COMMISSARY OWNER/OPERATOR I <br />Commissary Name / ` ., c; i i i FA# <br />Address ��� S. �� i C- /1 Bus. Phone 0S <br />City Le -,P/ Zip ., [_JWner/Operator .2 ri� ' k, <br />Check all appropriate services provided: <br />Wastewater disposal Pa 3 -compartment sink O Electrical hook-ups <br />Solid waste disposal [j[ Food preparation Toilet and handwashing <br />. Hot & Cold water for cleaning PU Store refrigerated food Potable water <br />Store dry <br />y�food/supplies JJ [3 Overnight parking E3 Vehicle wash <br />V C I , ri `, �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 condition of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall nott e EHD i ediately. <br />Signature L Date <br />13. To be completed by the ENV HEALTH iurisdiction outside of San Joaquin Co. <br />The commissary is located in County. The above food facility meets the <br />commissary requirements in California Health & afety 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 />