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SHAUN Environmental Health Department <br />Greotness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility :t 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 /1/D1n NorN GiGyai ���iL Lic. Plate # 64 F <br />Owner/Operator Name c vDce-r"T <br />Business Mailing Address_ / `/Z J <br />City State C-4- ZipEZoz Bus. Ph. 20 9 4,$,1 Alt. Ph. -2-0q- 3oz 00/i <br />1, e ✓STT i �A-7 , 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 penalties. <br />Signature <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary (Name rrL I � +l U'r h l 'i r (d 1 i i (i,� 1� i�'V ' i FA# <br />Address INC � _ 0 I I �V � I �1 U ! Bus. Phone (I ( bl) I <br />City, 1 V Zip GIS 2V) Owner/Operator RMTOR O//,,R <br />Check all appropriate services provided:/ <br />[Wastewater disposal W3 -compartment sink �T' <br />lectncal hook-ups <br />olid waste disposal Food preparation ile# and handwashing <br />�ot &Cold water for cleaning YO�vernight <br />ore refrigerated foodahle water <br />f3T Store dry food/sup lies arkin Li}' Vehicle wash <br />pnpP 9 <br />I, Ei' i l� a �� U �(, i' I ,5 ��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 condit' s of this agreement, or if this agreement is modified or cancelled, the <br />commissary o shall noMy the D imm tely. <br />Signature Y _ Date (k <br />3. To be completed by 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 & 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 <br />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 />