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ADV M� <br /> c°G{ SAN J0AQU I N Environmental Health Department <br /> i � COUNTY <br /> °9t,Fo <br /> T Greatness grows Fere. <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 (f1/CCm69 f/ c E CPZ E )'I ryr Lic. Plate# qg"/-1 92 <br /> Owner/Operator Name S-17f1L S'r fycr f-F <br /> Business Mailing Address /6' LJ fjO-T i L C /=o R c E S 7 <br /> City r»A fV 7& C P -StatecpZip 9 S 337 Bus. Ph. :1-ci- j<�j o-a,6 t 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 penalties. <br /> Signature Date 3--'7) a <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name P I C K rL. G o 9 c cRE m FA# <br /> Address 3L/ / D, L M i N c_ R r- v1-2 Bus. Phone `i;L,-A— 01 1A - I1 '� <br /> City S'7o C Tnrl- Zip CP C, 5,),, s Owner/Operator <br /> Check all appropriate services provided: <br /> p Wastewater disposal 13 3-compartment sink Electrical hook-ups <br /> p Solid waste disposal O Food preparation Toilet and handwashing <br /> 13 Hot & Cold water for cleaning "'M Store refrigerated food 0 Potable water <br /> 13 Store dry food/supplies _"Q Overnight parking 0 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 S�1�ra.,, �� ,'� 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 />