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SA N d OAQ U I N 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 completed b// APPLICANT / } <br /> Business Name P I�14, S �/ On.c+/��eao Lic. Plate# (1/ A3�% b <br /> Owner/Operator Name &Vc, <br /> Business Mailing Address <br /> City 1 State—Zip Bus. Ph. Alt. Ph. <br /> I, re IIL.p W OVOk , hereby state that the above information is current,true and correct to <br /> the best o 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 pe Iti s._ <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OP_ERAT,OR ,. <br /> Commissary Name [ 1 I Qy )err r, e,V,2@14 FA# <br /> Address 7i(/ y0 S. 4 r.oa.(-�- li✓ Bus. Phone 20 !f - V66 <br /> ,• <br /> City SJ-clzz orf Zip of SZO' Owner/Operator 9C'J 2v5 a <br /> Check all appropriate services provided: <br /> [wastewater disposal B'3-compartment sink Def-lectrical hook-ups <br /> Cf Solid waste disposal "Food preparation L--"Toilet and handwashing <br /> DHot & Cold water for cleaning [3'�Store refrigerated food E(Potable water <br /> / <br /> G Store dry food/su�ppli'esJP'�Overnight parking 1121Vehicle wash <br /> 6,C_) 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 ' 7/ �ic &A-D- _ <br /> 3. To be completed by the'ENV'HEALTH brisdiction outside of San J66qui 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 ewvw.sjgov.org/ehd <br />