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° SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> Greatness grnwc ho, <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 0- L Lic. Plate# yg054Z1 <br /> Owner/Operator Name So fq2 Zama vcA <br /> Business Mailing Address 20Oq S. MON1206 ST <br /> City M(,Mk\[ state CAR Zip'15200 Bus. Ph(�fJtl)c51o�-'1(3q T AIt. Ph. <br /> 1, -TO-C en Zo.wvJ Y rn hereby state that the above information is current,true and correct to <br /> the best oTmy 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 pe alties. <br /> Signature Date (� 29 2020 <br /> F2—. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Nam �0 <br /> Add res D S• ar a to Bus. Phone Z <br /> Cit Zip S2 0 Owner/Operator <br /> Check all appropriate services provided: <br /> �Wastewater disposal f"'- partment sink CC3"E1lectrical hook-ups <br /> Solid waste disposal Food preparation B Toilet and handwashing <br /> .H Holt& Cold water for cleaning �tor ngerated food O'Pota a water <br /> .1 t re dry fo /supplies vernight parking ehicle wash <br /> I, L hereby state that the information I have provided is current, true and <br /> corrKKoYhe bes my knowledge, an 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 /> commissa wrier stpil notify the EHD im diately. <br /> Signature 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 />