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SAN JOAQU!N Environmental Health Department <br /> —--COUNTY------ <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility -o 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 r� <br /> Business Name 1 Q c"'s -Mcos n Lic. Plate# <br /> Owner/Operator Name CA C.h�t-e- rb Gl' fe'f-c- <br /> Business Mailing Address I L <br /> City (Y1 lJ r)4)(CA State C-ft ZipLI<-336 Bus. Ph. 10(069-qi?'� Alt, Ph. <br /> I, �4 CAC V)a-- hereby state that the above information is current, true and correct to <br /> the Nest 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. � <br /> Signaturea2 z &k2' 4 Date Zl-l� - 20211 <br /> 2. To be Completed by COMMISSARY OWNER/OPERATOR <br /> - <br /> 11 <br /> pv <br /> Commissary Name i ,Aq e d 1 Iu. l FA# <br /> Address—LIm rpm s WGA= Bus. Phone L! <br /> City S� Ck+� Zip wner/Operator <br /> Check all appropriate services provided: <br /> 6 Wastewater disposal K-24--compartment sink OrElectrical hook-ups <br /> Solid waste disposal d Food preparation W—toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food '1Potable water <br /> S, re dry foodlsuppplies 2/Overnight parking ��Vehfcle wash <br /> 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 shat EHD immediately. <br /> Signature <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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />