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SAN JOAQUIN Environmental Health Department <br /> '" ! ---COU NTY-- <br /> ureotness 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 &amtw C�� cjp_�dm Lic. Plate# l r/0 V <br /> Owner/Operator Name jj M j 4y i 'E2_ Qkq Iq <br /> Business Mailing Address C Sx�-��w] �- . �p i T' <br /> City <i ocjc l v­ri Statet(-AZip'3.0Bus. Ph.�,3g-. ty,Zo —�G`77 Alt. 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 p <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name T ) CK !� j:o 4c c Cg c- j3n-7 FA# ICK , r� w <br /> .. .. <br /> Address 3V/a /p•��/Yr=t7 a rc Bus. Phone 2),301-- t�A`� 7g1�tAf,1�R " E. <br /> City S�v cic%csv Cj Zip q S'a0 5 Owner/Operator �gTOCKTON, CA 95205 <br /> Check all appropriate services provided: <br /> E3 Wastewater disposal E3 3-compartment sink __AZ Electrical hook-ups <br /> p Solid waste disposal [3 Food preparation ---,Q Toilet and handwashing <br /> O Hot & Cold water for cleaning --0 Store refrigerated food 13 Potable water <br /> Store dry food/supplies Overnight parking O Vehicle wash <br /> 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 shall notify the EHD immediately. <br /> Signature, � � � 1`a' 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 />