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SAN J O A Q U I N Environmental Health Department <br /> ---COUNTY �7 ��CEIV [... <br /> � <br /> Gr`eatneis t�rt?s�r5 i72re. � ; t <br /> COMMISSARY AGREEMENT MAR 18 2021 <br /> Mobile Food Facility , Caterer ENVIRONMENTAL HEALTH <br /> -ERMIT/SFF<.MA-'.') <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 <br /> by APPLICANT <br /> Business Name �� G 1 /9 r5 �� t �C J C (d Lic. Plate# `!�h'��4,(t1 <br /> Owner/Operator Name ,/i k j)�� h fv re- LC e`1V f)kb 1 <br /> Business Mailing Address llewA'77)A! 11M. <br /> City S`�b l�C T c� State� Zip`3�2 Bus. Ph4,z 417C Alt. Ph. <br /> I, l�z/)C d 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. <br /> Signature Date 3 ( r �/� 0 2-1 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name t; l 1✓Gj QJ1_CCA f/L! U,-,:k C&A;TE Z FA# <br /> Address 12 5. Lkltlli' -ST Bus. Phone(::�e' <br /> CityS'G&AT0l�1 (A Zip 95-D C, C, Owner/Operator L7 k r /46 u <br /> Check all appropriate services provided: <br /> ®'Wastewater disposal lid"3-compartment sink Er Electrical hook-ups <br /> 11'Solid waste disposal G""Food preparation 4-Toilet and handwashing <br /> 17 Hot& Cold water for cleaning Store refrigerated food Eg-'Potable water <br /> Cr'Store dry food/supplies U Overnight parking ' Vehicle 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 owe shall notifv the EHD immediately. <br /> Signature Date <br /> r3. 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.or /ehd <br /> F (3 C) 2 `4 92 <br /> PC� o-�s '-� 3�0So 5 <br />