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SAN 10 A Q U I N Environmental Health Department <br /> — - COUNTY <br /> GreatrE�S� grows /2ef'£. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 11. To be completed by APPLICANT <br /> Business Name 66RC4j Bum 511111Ig fCC Lic.Plate# 9,1116313 <br /> Owner/Operator Name 51-Etir,6/V !�_u Gc C (346 IJ T <br /> Business Mailing Address -5-9-?q PR C/ r1 c b <br /> City yO CfCrl1Itl State C 4 Zip 9.SZo? Bus. Ph.f 9,_'�— �977 Alt. Ph. <br /> 1, 5T-eyew G-RA IJP , 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 holderVi4qt notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. — - - ----- <br /> Signature - Date 3 r 9/Z o 2- 0 <br /> 2. Tobe completed by COMMISSARY OWNEMPERATOR <br /> Commissary Name I "' �} 1�1(: j') "FA# <br /> Address ,S - `�1� ! 7t 1 �S T Bus. Phone_ C�112q`.� �`ttLU <br /> City ��(�k "C��l Zip q�2_Cjc; Owner/operator Yjt-a 1' . <br /> Check all appropriate services provided: <br /> Wastewater disposal CY"3-compartment sink tT Electrical hook-ups <br /> Solid waste disposal C/Food preparation CT/Toilet and handwashing <br /> 13/Hot& Cold water for cleaning L/Store refrigerated food ice" Potable water <br /> 1-1,"Store dry food/supplies d-Overnight parking M Vr�ehicle wash <br /> I, L Y61d-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 s II notify the EH immediately. n p� <br /> Signature <br /> —ni—C C Date G3 I lid <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 />