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SANAOAQUIN Environmental Health Department <br /> `t COUNTY— <br /> `:G 'r 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_._ //-:11. <br /> Business Name U v U �ck l: t Lic. Plate# P i)Z F) 53 Z <br /> Owner/OperatorName ):C C;tciLA, <br /> Business Mailing Addressyoy (49 Y <br /> City \ IV YN StateaZipq,7l&Bus. Ph,;D-f Z&..,( <br /> 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 alifomia 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 /> Signatureul—le�1f - �".5eq DateD 7— Z� 7_22 2�O <br /> 2 Tobe com fel1ted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name l G t 1GDJv\`G1Ua, FA# <br /> Address `4/4v_N— Bus. Phone-Ielc <br /> City Ay^ Zip 1 r, o ; O ner/Operator <br /> Check all appropriate services provided: v` <br /> astewater disposal Z3-compartment sink . 0 Electrical hook-ups <br /> 'olid waste disposal O Food preparation 6d Toilet and handwashing <br /> ® Hot& Cold water for cleaning 13 Store refrigerated food Notable water <br /> O Store dry food/supplies 0 Overnight parking "ehicle 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 oer-s\h_al_l notify th EHD immediately. I n <br /> Signature �IJyr' ? i7/ / Date D ' N' !.0 <br /> 3. Tobe dornpletedby the ENV HEALTH jutiscliction outside of.San Joa uin 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.orglehd <br />