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SAN 1 Q A Q U I N Environmental Health Department <br /> --COUNTY <br /> Vrzatncss 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 by APPLICANT <br /> Business Name iGC. Lic. Plate# D <br /> Owner/Operator Name <br /> Business Mailing Address 33 C - 9Ao& <br /> City • — 1 'State&O Zip(!a Q7 Bus. Ph.A&77V4— 9 Alt_ Ph. ,iW� & S' a0 <br /> I, �_!GIUC IK( �14�C�LfC,'� , 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 iscontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation d e alties. <br /> Signature S Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address AC1aD �- Bus. Phone &q_7 7�( `4 S_Sb <br /> city , , ( Zip S Owner/Operator <�D j t pjIs <br /> Check all appropriate services provided: <br /> pa Wastewater disposal KI 3-compartment sink It Electrical hook-ups <br /> Solid waste disposal 0 Food preparation X Toilet and handwashing <br /> Hot & Cold water for cleaning 'U Store refrigerated food Potable water <br /> r tore dry fo d/supplies X Overnight parking X4 Vehicle wash <br /> l�•, <br /> I, hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, nd 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 /> commissay��Zer shall noti e EHD immediately. <br /> Signature � ri�G ur -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 />