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• F"U3N;0 <br /> -� S A N 10 A Q U i N Environmental Health Department <br /> _LSU i-JTY-- <br /> ���, � Ureatness 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 A CD Lic. Plate# <br /> Owner/Operator Name Pirp' <br /> Business Mailing Address aeC11,14ad <br /> City QCcI State ( ZipBus. PhD9— 7--OrJ?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 completedby COMMISSARY OWNER/OPERATOR <br /> Commissary Name G00'Ihjj'5 �% FA# <br /> Address �o ?-& 6 J?V�,r-j ,54 G(5��JO Bus. Phone- Te 1 -112- — �5 5 7 <br /> City Lo t)+ Zip 95Z-'10 Owner/Operator 09Irjki✓1dr0 45%616e�_ <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink EI ctrical hook-ups <br /> p�Solid waste disposal 0 Food preparation Toilet and handwashing <br /> IY Hot & Cold water for cleaning Store refrigerated food VPotable water <br /> ['Store dry food/supplies Overnight parking C3 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 g�Z*1* Amt._- Date <br /> 3. Tobe 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 />