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A Q�,Q(� Environmental Health Department <br /> — C 0 U N T Y---- <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 -0p �C) GS Lic. Plate# <br /> Owner/Operator Name (SSC R K L840- SK04(4 5--A� <br /> Business Mailing Address �VX 7 (--6))( C—KECK Rb <br /> City 2LOCOid State M Zip 9Y2l d Bus. Pq.r- 2 JL— q q b Alt. Ph. <br /> 1. 0,56-M- DUfy :-ft� S12, 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, th ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. l <br /> Signature tiL Date g�A Z 0 <br /> 2 To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name t,(, tbl� Ct'iTc—Ki(�C--rl, ac G �&-A- FA# <br /> Address 17/7 ,5 . a4�j etl 577 Bus. Phon '-2aC F-5gl <br /> City,' C K76-k , Cts Zip 96--104, Owner/Operator ��� 1-R 6 d <br /> Check all appropriate services provided . <br /> WAastewater disposal &"3-compartment sink M/Electrical hook-ups <br /> DRY/Solid waste disposal Food preparation 0"'Toilet and handwashing <br /> ILS Hot & Cold water for cleaning Store refrigerated food [( Potable water <br /> rl Store dry food/supplies ri1 Overnight parking Vehicle wash <br /> 1 �� //� 0'-) , hereby state that the information I have provided is current, true and <br /> correct t the ee 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 sh nthe D�irT,,moiately. <br /> Signature Date �Z7 1C>2D <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, Hazeiton Avenue I Stockton; California 95205 1 T 209 468-3420 1 F 209 464-0138 1 %AAv,Y°,!.sjgov.org.'ehd <br />