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SAN�IOAQU i N <br /> Environmental Health Department <br /> —COUNTY— <br /> ,F - <br /> `9coaGreatness 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 � Lic. Plate# <br /> Owner/Operator Namere-SU <br /> Business Mailing Address ItNo ' <br /> City Stated Zip Bus. P .�o2Uy�a�7.�,Z�S&eAlt. Ph. <br /> I, le:w 42A.0—_ C Gj/ , hereby state that the above information is current,true and correct to <br /> the best of my knKledge 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 P I C K GtF r) a c j, cA (qM __FA# <br /> Address 3f rr e, AD Bus. Phone `�' "(' �( yi F`� /7 (,-0a <br /> City S'7'o CjCZip of S'�+f Owner/Operator S;g7,o✓,*917-7 n'ry akS` ilin4j' <br /> Check all appropriate services provided: <br /> p Wastewater disposal C] 3-compartment sink Electrical hook-ups <br /> El Solid waste disposal M Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food Potable water <br /> E3 Store dry food/supplies Overnight parking [3 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. f'- ' T 00IC ryE.�11y1 <br /> C.ARPI- -,R RD. <br /> Signature � � �' �l Date <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 />