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Q Q N Environmental Health Department <br /> " b. COU N T Y <br /> rq� ? Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be completed byAPPLICANT <br /> q <br /> Business Name S I D h 1GG� (J'__�_ c9 R M ' Lic. Plate# 7�_S 6 o I� C <br /> Owner/Operator Name_<�" ug_:�(T - V,- R Uy- ( A 13 LI"1 <br /> Business Mailing Address 40Va ` <br /> CityS—tbCJ�-- . State zip ZBus. 4ADct) Q I S-_j q l 1 Alt. Ph. `'tel <br /> l 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 J )+ b J Date 2' <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name e <br /> ) C KZ6'o —4c-'T C R 'A (n FA# <br /> Address 3 L4 l � L - gM I' of C R 0 VC Bus. Phone ':3�01-- ()\Ul Y-^ 1`�U1�) <br /> City � 77.0 CK-re) Zip C, e1 Sr SLo Owner/Operator _! r� -'/Y' A M <br /> Check all appropriate services provided: <br /> p Wastewater disposal 0 3-compartment sink '\Q Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> CI Hot & Cold water for cleaning _'M Store refrigerated food ❑ Potable water <br /> A <br /> ' GO ICE CREAM <br /> E3 Store dry food/supplies Overnight parking ❑ U�M MINER AVE. <br /> I, f lFNatw -ro," 4;K SW�n� herebystate that the information I have 3 1 tri? in <br /> and meets the California Health&Safety Code re p-A tilft`y- <br /> 65205 <br /> correct to the best of my knowledge, y q y <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 i.("' ',1K ' 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 />