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SA �� QA Q (N Environmental Health Department <br />w� l r:. C o u N y. --- <br />cq � Grectness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed <br />by <br />APPLICANT <br />Business Name, <br />_D <br />„ <br />n <br />Lic. Plate # 2YO G 3 <br />Owner/Operator Name be 'o cc^Q' I <br />Businesp Maijina Address V6 L,5 Vj ' ref <br />City ( G 0 State CA -Zip I Bus. Ph. <br />Alt. <br />21110 <br />I, , hereby state that the above information is curreht, 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 oice may result in permit <br />revocation and a (ties. <br />Signature _ :-_ _ - - Date <br />[2. To be completed <br />Commissary Named-� <br />Address��t S <br />City 7 r <br />COMMISSARY OWNER/OPERATOR <br />G- W K# FA# <br />f� Bus. Phone (L�C���//// ✓1 �U� <br />Owner/Operator 7L/� lS Y J-1 A t -�- <br />Check all appropriate services provided: <br />Wastewater disposal =compartment sink d�E ectrical hook-ups <br />0 Solid waste disposal �Food preparation �/Pot/able <br />flet and handwashing <br />�ot & Cold water for cleaning Q Store refrigerated food water <br />0 Store dry ood/s plies Overnight parking C Vehicle wash <br />I, 2)1vi i ' At -fl hereby state that the information I have provided is current, true and <br />correct to the best of y knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to cly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owrye mss. I no the D immediatey. <br />Signature // Date /�� 12,:-) <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 rneets 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 />