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} � SA �Q�Q� � Environmental Health Department <br /> r .., <br /> 'WL __.00U NTY.-_....... <br /> 1tr�oa�'p1, 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 by APPLICANT j vINS <br /> %i�✓�%%%�% /% iii%'�i//e//%%%%//� ��% ✓y%'✓ <br /> % ,y y ,, <br /> Business NamejQ( c) EL RG-4 07_te.CC_ Lic. Plate# l 225oz <br /> Owner/Operator Name�Ll_11°\�� j' \G�eft-ya �--w e 2- <br /> Business Mailing Address GACCk f CA�C.(?A-�7) �-n <br /> City LQC r�State (_ZipC�Bus. Ph�)'}t-D-95 U Alt. Ph.�)'-(�0 <br /> I,�Q��\, �Y�\CU edre\ , 0 . hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree tb 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 /> ✓o�. �, ��� �y ✓. <br /> Commissary Name 4W aGl#�� J L? j 7yl <br /> Address & Bus. Phon _c <br /> City Zip 5 In Owner/Operator ] <br /> Check all appropriate services provided: <br /> astewater disposal W3--compartment sinkle ical hook-ups <br /> olid waste disposal © Food,preparation oilet and handwashing <br /> _,, i <br /> �7�y <br /> old water for cleaning ;;Ze <br /> e frigerated food f otable water <br /> food/su lies night parking ehicle 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 mply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o r all no ' the D immediately. f <br /> Signature '�' I Date ��� / p7 a <br /> L3. 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 />