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1U N <br /> ° ° Z SA6JOAQUIN Environmental Health Department <br /> �l <br /> —COUNTY- <br /> 4L. <br /> OUNTY <br /> c�4L.IF: `P 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 <br /> Business Name a ( �(�� Lic. Plate# I g 0 5 5 <br /> Owner/Operator Name 1=SO e Q N&!rA-v A Z <br /> Business Mailing Address ''q GQ tj N-\kPj q �" <br /> City S" �Ck "�1 State CC Zip ,j( Bus. Ph.(de`� �5 -4 445 yglt. 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 penaltie . <br /> Signature aad, <br /> Date I a`� —) i✓ �- C� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary NameFA# <br /> Address j S 5�C-"Ci Me tA tj- Bus. Phone <br /> CitC u- Zip 951\4 O Owner/Operator csbi c' CAAV <br /> Check all appropriate services provided: <br /> p..Wastewater disposal 11/3-compartment sink 111-Electrical hook-ups <br /> p Solid waste disposal 0 Food preparation mllr�ilet and handwashing <br /> 0-14 t& Cold water for cleaning more refrigerated food O-Potable water <br /> ('1 Store d food/supplies 0–Overnight parking C"ehicle wash <br /> I, -A1 U (JC,4 , 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 all notify the EHD immediately. <br /> Signature CLila �+ Date <br /> 3. To be completed by the ENV HEALTHJurisdiction 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 />