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� e <br /> °{- , SANsJOAQUIN Environmental Health Department <br /> utr COUNTY-- <br /> `''�°qt '• 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 . R Iylv a ;C� Cts ti(-,I Lic. Plate# l%/o c? <br /> Owner/Operator Name a M v hi j c PIE C41d 0, i';°4 <br /> Business Mailing Address <br /> City S QCic I D')j Stater QZip , Bus. Ph.j,c• 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 p aft' <br /> Signature Za Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 1 CK o -5 C E CAE J3 "7 FA# Of K , W <br /> C-=, .'- t <br /> Address 3`f/a 'i�� e rc_ Bus. Phone 5-q--City 47 cg%cly CA Zip q S'_!�_J S Owner/Operator 0 4,,, STOCKTON, CA 95205 <br /> Check all appropriate services provided: <br /> ❑ Wastewater disposal 13 3-compartment sink ��Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation �� Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning Store refrigerated food ❑ Potable water <br /> Store dry food/supplies Overnight parking ❑ 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 /> /7 <br /> Signature`s �,,�.,� ..( , f 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />