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Environmental Health Department <br /> COur,IT - <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 ( /�7 G+�% / ( a Ila r Gn � Lic. Plate# <br /> Owner/Operator Name C�CGZcfr5 e <br /> Business Mailing Address1g1/:� l�f�L�UCr7 ST <br /> City >! r7 tatejAZip 5U/j Bus. Ph. Alt. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> the best of my ki edJe 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. <br /> Signature Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name lk Il Ru/'n If,, �� Si ?TFA# <br /> / <br /> AddressBus. Phone 7 cJ E <br /> City )TZ C' YI ZipQ52Z&2.� _Owner/operator <br /> Check all appropriate services provided: <br /> ✓Wastewater disposal ��-compartment sink i Electrical hook-ups <br /> y i�olid waste disposal ;.Food preparation ?Toilet and handwashing <br /> L Hot & Cold water for cleaning Store refrigerated food `:Potable water <br /> Store dry food/supplies 4/Overnight parking i':. Vehicle wash <br /> I, �� � 3 t J hereby state that the information I have provided is current, true and <br /> cor�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 l� 3 C <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 I %wAv.sjgov.org/ehd <br />