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SANJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness 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 com feted -by APPLICANT <br /> Business Name 19 PA- /CC CP-IF-4'� Y11 Lic. Plate# 6 "KQJ 684 <br /> Owner/Operator Name �oj�Sl.)Q) ? GLY1f7 <br /> Business Mailing Address--s:9 6 q a✓g <br /> City SiZiCK-re; Statect*Zip Ok Bus. Ph. tnoR-- " Glt-g3 It. 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 penal ' <br /> Signature/�'�.—= Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name CK N u 4 c c pm FA# <br /> wn <br /> Address 34 I� C. rn1 ry� a Ave Bus. Phone �a�t� ��P- ��\A O 7C <br /> %) N <br /> City STa cK%ae✓ Zips a s sic- Own6R/Operator A M Z <br /> 4 . G) <br /> Check all appropriate services provided: O O <br /> Z <br /> p Wastewater disposal E33-compartment sink \0 Z Electrical hook-ups n m m <br /> p Solid waste disposal C1 Food preparation Toilet and handwashing D X <br /> n <br /> lD Hot & Cold water for cleaning SSI Store refrigerated food O Potable water N C m <br /> E3 Store dry food/supplies Overnight parking ❑ Vehicle wash 0 m <br /> 3 <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_ q� -Cati , - Date 77-141 2c. <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 />