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UI;; , SAN 1DAQUIN p <br /> � Environmental Health Department <br /> COUNT Y <br /> tgc,re�a;7` Grectness 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 cp R t, e S 4 '�L_ CRC^14M Lic. Plate# Pb'('S'14 C'/a Aq- <br /> Owner/Operator Name C I_a c A/ V p 1A E- <br /> Business Mailing Address :Z_5 'z v` c 0.,1 ±p <"-r <br /> City S is StateQ1 Zip qS�--<'- Bus. Ph. L4 9.5'i 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 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name i C r a1/' ei C 4e- 5- C'geao"7 FA# <br /> Address Bus. Phone a­ -- C� r-- (4 <br /> CitZip C9 S2 d S Owner/Operator Sj4T1/'Pn--,? H <br /> Check all appropriate services provided: <br /> p Wastewater disposal D 3-compartment sink �. �� Electrical hook-ups <br /> p Solid waste disposal '� [3 Food preparation `� Toilet and handwashing <br /> O Hot & Cold water for cleaning` '`n Store refrigerated food E3 Potable water <br /> 0 Store dry food/supplies Overnight parking 0 Vehicle wash <br /> I, , 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 conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediately. <br /> Signature s,,, , � �^ Date a_a <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 />