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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 MR at GCO-S I SU)rJ7A �Q I Uc.Plate# <br /> Owner/Operator Name !SE_Fl N f::)QU trJO <br /> Business Mailing Addressddo e-Po r z. L.+S <br /> City1AaTIi-SCA StateCA Zip S�Bus. Ph.(209�.53$3Alt. Ph. <br /> I, P�y trV) , 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, an an Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is s ontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p nalties. /5/� <br /> Signature Date //r 2 <br /> be completed bV COMMISSARY OWNER/OPERATOR <br /> Commissary Named N10 n) Ct416RIId f, Tack ceNrr:R FA# <br /> Address-1 7 f7 S 4(&0,41 Sr Bus. Phonc—. f2DR� 'oZ . ^S�l <br /> City_ St KTw'RJ CR 95. <br /> Zip 2 06 Ownerloperator / T IRII dy <br /> Check all appropriate services provided: / <br /> [(Wastewater disposal ER�3-compartment sink L��/Electrical hook-ups <br /> Ey Solid waste disposal 0 Food preparation f� Toilet and handwashing <br /> Cid Hot& Cold water for cleaning G Store refrigerated food Cff"Potable water <br /> Or-'Vehicle <br /> M"Store dry food/supplies a-,overnight parking wash <br /> ,, /1Rr 7-4 Iq d o , hereby state that the information 1 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�I notify e EHD immediately. <br /> Signature <br /> �� "( Date 1 ,!�_ 2 G z <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 1 www.sigov.org/ehd <br /> SR FORw,,_, . <br />