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---C U U r4 TV------ <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 9 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> Jo be completed by APPLICANT <br /> Business Name A 'C 9 c F- Cg C p[i'1 Lic. Plate# t A I SG4 <br /> Owner/Operator Name ,11- �-j (-,l S;Al 0, N <br /> Business Mailing Address 3LI 1 L-2, m jj/z5'R 64V[= <br /> City State <br /> Zip of SSkpS Bus. Ph. 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. p <br /> Signature 1-1-c—, - Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name P 1 CY\ o CR C FA# <br /> Address S`;"o Cr(' %o/-L / ce�- Gi S N I S'' Bus. Phone <br /> City Zip Owner/Operator -j t,s 0 <br /> Check all appropriate services provided: ® o% <br /> \�-, Z <br /> -C-;. Wastewater disposal 3-compartment sink \ Electrical hook-ups M <br /> Solid waste disposal --I Food preparation `'till Toilet and handwashing Z - C` <br /> Hot & Cold water for cleaning Store refrigerated food C- Potable water 0 M 0 <br /> \ W_ Pri <br /> M Store dry food/supplies Overnight parking 177- Vehicle wash 0 <br /> I, hereby state that the information I have provided is current, true andN M <br /> correct to the best of my knowled6e, and meets the California Health&Safety Code requirements. If the food facilitypi > <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the( <br /> commissary owner <br /> -.shall notify the EHD immediately. <br /> Signature Date G <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 209 408-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />