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2SAN�IOAQUIN Environmental Health Department —COUNTY- 7l " Greatness grows here. COMMISSARY AGREEMENT Mobile Food Facility♦ Caterer Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. 1 . To be com feted by APPLICANT Business NameR--F J F ucf4 M Lic. Plate# S R 1 S J S-7 Owner/Operator Name G k R M ECT -V; rVq H Q 61 r a B Business Mailing Address �?\A 6 1 \ 6(�C�L 7 t R DR City rn((t-r F CA_Staterffi_Zip o,s 3.57 Bus. Ph. �13r\ — -)U 6�-\ Alt. Ph. I, , hereby state that the above information is current,true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit revocation and penalties. Signature . Date % 2. To be completed by COMMISSARY OWNER/OPERATOR Commissary Name F 1 C JC t'/ g o 4 C 5 CSP Qm FA# Address 3 N 1 `1 C rn i ry q qyc- Bus. Phone Cit Zipga a S`10 S`Own /er Operator _j W 0 Check all appropriate services provided: 0 to � Xmz ❑ Wastewater disposal ❑ 3-compartment sink Electrical hook-ups - G) p Solid waste disposal ❑ Food preparation `Q Toilet and handwashing Z 3 O C3 Hot & Cold water for cleaning �© Store refrigerated food O Potable water n m n M ❑ Store dry food/supplies �❑ Overnight parking ❑ Vehicle wash > D n I, hereby state that the information I have provided is current,true and N C m correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility N 171 D operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the commissary owner shall notify the EHD immediately. Signature ��s S L��.� ri Date 1.3. To be completed by the ENV HEALTH j.urisdiction outside of San Joa uin Co. The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safely Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd