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2' ' °z;; SAN- OAQ U I N Environmental Health Department <br /> COUNTY <br /> 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 b APPLICANT <br /> Business Name o- e-v `(" Az�Jc-G4. Lic. Plate# f <br /> Owner/Operator Name t �� /��'�- ��-' `� <br /> Business Mailing Address ( - 2- <br /> City V V,_k, L StatZip �/* I Bus. Ph. ) /t?- C _Alt. Ph. <br /> 1 ILU15 P-04 �, c,� 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 pena " s <br /> Date C(7 /�yf t <br /> Signature <br /> 2: To be completed by <br /> COMMISSARY OWNER/OPERATOR <br /> Commissary Name Z-0-5 )"ck5 FA# <br /> Address I 0:,, . 1 bPYrx- C) !S Bus. Phone <br /> City 14"y-,Ili },��� Zip Owner/Operator �� <br /> Check all appropriate services provided: <br /> (3 Wastewater disposal M-3--compartment sink 13 Electrical hook-ups <br /> )if' Solid waste disposal 92"Food preparation ff Toilet and handwashing <br /> L1 Hot& Cold water for cleaning 0 Store refrigerated food Potable water <br /> Store dry food/supplies 0 Overnight parking E3 Vehicle wash <br /> 1, -,, , 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 co ply ith the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner s notify the EH0 im teiy. yy <br /> Sign ure C �t? e7e�� Date 10 <br /> 3. To be completed by e 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 />