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S A N J O A Q U I N Environmental Health Department <br /> —_.COU N T Y----- <br /> ` Greatness 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 by APPLICANT <br /> Business Name 041 �2 Aj cz' Lic. Plate# 'j`� �/,!5/"%� <br /> Owner/Operator Name_ <br /> Business Mailing Address -2-9- C <br /> City. !1 L Statej�'Lip f_ <br /> Bus. Ph,rt'XI- Alt. Ph. <br /> I, , 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 Date rOl /C <br /> 2. To be completed by-.COMMISSARY OWNER/OPERATOR <br /> Commissary Name (. '� FA# <br /> Address %� Lf/ GCS` SGC Bus. Phone ref!`✓�` - `'` ?L <br /> City `�'7 Zip S Owner/Operator„e rr � <br /> Check all appropriate services provided: <br /> I Wastewater disposal 11 3-compartment sink © Electrical hook-ups <br /> 03 Solid waste disposal 0 Food preparation 19 Toilet and handwashing <br /> IN Hot & Cold water for cleaning C1 Store refrigerated food CSI Potable water <br /> E3 Store dry food/ uppIies E3 Overnight parking Ill Vehicle wash <br /> I,tt� 1i��1'� nC hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledVel and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the��'ditions of this agreement, or if this agreement is modified or cancelled, the <br /> q <br /> commissary r�r shall notify tb/EHD immediat y. <br /> Signature f�`.fi-l: � �✓v7��1� --- Date <br /> Y <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 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 />