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• • �'� '��` SAN:J O A Q U I N Environmental Health Department <br /> 4-, ae� Gr eo ness grows here. <br /> RECEIVED <br /> COMMISSARY AGREEMENT FEB 10 2020 <br /> Mobile Food Facility s Caterer ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <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 ) U � 0 Lic. Plate# <br /> Owner/Operator Name (IItI15 ' <br /> BusinessliMmailing Address Gi IsIGI <br /> City L�l State ,Zip Bus. Ph. Alt. Ph.C�� ✓ <br /> 1 hereby state that the above information is current,true and correct to <br /> the est of my knowledge and agree t ut ize 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 b COMMISSARY OWNER/OPERATOR <br /> Commissary Nam 111 (,� <br /> .Address r Bus. Phone <br /> ��,-6 Q <br /> City Zip Owner/Operator �� <br /> Check all appropriate services provided: <br /> 0- <br /> �Nastewater disposal C�3`3�-compartment sink 0 Electrical hook-ups <br /> /Solid waste disposal B Food preparation C�'Toilet and handwashing <br /> I<d Hot & Cold water for cleaning 0 Store refrigerated food ® Po able water <br /> ® Stor dry food/suppli sT Overnight parking Vehicle wash <br /> 1, 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 /> commiss owner shall n tify the E immediately. � <br /> Signature Date UT <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />