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;. . . .. SAN JOAQUIN ErMifoF&mental Health Department <br /> _ - COU I-JTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4r Caterer <br /> Complete sections 9 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_Ve'uh bnrJ 1t'ri w� S Lic. Plate# <br /> Owner/Operator Name 1w C4 SSG Gu_ Z_ _ <br /> Business Mailing Addressl J 0 <br /> City _/TDC Stated zip SZ Bus. Ph.2 d? &Q&.Q�� Alt. Ph. <br /> I �f llr� � a P�� 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 disco ued, the perm' holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pens ties. <br /> Signature Date r <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName �_i (zx at/ CTO _YCE CRCL17 F'A# <br /> Address_ cy C !r7/171-CA A ✓L- Bus. Phone <br /> City Zip Owner/Operator <br /> w <br /> Check all appropriate services provided: 0 <br /> 0 Wastewater disposal E2 3-compartment sink electrical hook-ups 0 m Z <br /> iD Solid waste disposal 0 Food preparation U—'Toilet and handwashing Q <br /> zic0 <br /> 0 Hot & Cold water for cleaning 7G—Store refrigerated food C� Potable water Z 0 <br /> L: Store dry food/supplies :WY�vernight parking � Vehicle wash n X 0 <br /> I, hereby state that the information I have provided is current, true and U, C M <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility 00 m <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the ch <br /> commissary owner shall notifythethe EHD immediately. <br /> Signature � �-: <S-,i•� �, �7 _ ,Date <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.sjgov.org/ehd <br />