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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 leted b APPLICANT <br /> Business Name FV,1 IS Lic. Plate# <br /> Owner/Operator Name r <br /> Busin ss Mailing Address �? <br /> City-L StatefaZip us. 41.y a-DgDj 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 p rmit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and peL alties. <br /> Signature � Date l0� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 6004GyJr S� V y ����1lc FA# <br /> Address 1020 S 5�t<k&t4v& 5h' Bus. Phone <br /> City0121Zip 45Zri�U Owner/Operator /9 ;?Wlro 66"ecl <br /> Check all appropriate services provided: <br /> � <br /> Wastewater disposal O'3-compartment sink Electrical hook-ups <br /> U�/Solid waste disposal O F�od preparation Toilet and handwashing <br /> WHHo/o't & Cold water for cleaning M/Store refrigerated food Potable water <br /> 5' <br /> Store dry food/supplies Overnight parking 13 Vehicle wash <br /> I, e4w✓ , 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 Date '/6' —.25 — ZO ZD <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.sigov.org/ehd <br />