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SAN J OA U U ] N Environmental Health Department <br /> _C 0UNTy..... <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 _:V,1� GC- e�\,S Lic. Plate# TZ <br /> Owner/Operator Name i Oe Cly <br /> Business Mailing Address Q d <br /> - jbn' �hC <br /> City \' oy� State Q4+Zip S_j us. Ph. Alt. Ph. FO d —70y <br /> I, hereby state that the above information is current, true and correct to <br /> the best of my knowledg a 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 per Ider must notify the EHD. Failure to notify this office may result in permit <br /> revocationenalties. <br /> Signature Date �� Y�ae� 0 <br /> 2. To be completed b MISSARY OWNEWOPERATOR <br /> Commissary Namel��l�/�1 C � ��l�t/G l i'��1� C��r�i�� FA# <br /> Address 1 7V7 s v y01or�' SUEt-- t Bus. Phone 07 <br /> City -51-0 GKR9Pj, C,q Zip �� ���G Owner/Operator Rh6o K", <br /> Check all appropriate services provided: <br /> a-wastewater disposal C3/-3-compartment sink 13'Electrical hook-ups <br /> _t olid waste disposal ET"Food preparation M Toilet and handwashing <br /> #1"'Hot & Cold water for cleaning 0 Store refrigerated food G'PPotable water <br /> G' Store dry food/supplies M/Overnight parking Vehicle wash <br /> I, Ay d( U , 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 tify the D immediately. <br /> Signature /,,-[� Date -JAZ V 2 ;7— <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 />