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SAN J O A Q U I N Environmental Health Department <br /> ----COUNTY— <br /> G,eatness gros+s irre. <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 ff,, <br /> Business Name Lic. Plate# 7c�3 <br /> Owner/Operator Name t e k C J60 r L, <br /> Business Mailing Address 2 iQ�c� t� C+ <br /> City c 10D) State(14 Zip Bus. Ph. I0--d2WAIt. Ph. <br /> �Z 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 penalti <br /> Signature Date 2^ZVZ1 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name CQmmiS_cdCA AZ c,2 FA# <br /> Address oZ o S `'Q CG �i'co S f Bus. Phon4 20 9 2Z L-(—P�' 33L� <br /> City L \ Zip Cr52-` O Owner/Operator �fh�CC� �iCG��N nC1CU C kkC � <br /> Check all appropriate services provided: <br /> Ig Wastewater disposal q 3-compartment sink Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning ` 1 Store refrigerated food i Potable water <br /> L) Store dry food/supplies F1 Overnight parking Vehicle wash <br /> 1 CMtkc-L�� T(CiGhereby state that the information I have provided is current,true and <br /> correct to the best my knowledge,ahb 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 t EHD immediately. <br /> Signature Date <br /> 3. To be corn leted 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 1 www.sjgov.org/ehd <br />