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l° °.V�'"' •°i' SANAAQUIN Environmental Health Department <br />—COUNTY- <br />-'Ove,`'•' Greatness grows here. <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 <br />/ <br />Business Name R P, R Ci Vy Lic. Plate # C HT1' <br />Owner/Operator Name%S f JNJ 2f �!" 11 a <br />Business Mailing Address e, P• ✓ J7O <br />City f'�oC/�fa t State_C/I Zip9�Bus. Ph. Ph. <br />I, , 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 penal' s. <br />Signature Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Q 1 C j< N q1 tJ g C 4_ CRC_VC'7 FA# <br />Address3�l 1 `� L M frrV F R A V F Bus. Phone a2= H— Q Al-- 1'1 kA <br />City S To C k Tani Zip cA�1 SRo S Owner/Operator W <br />Check all appropriate services provided: 0 A <br />N <br />p Wastewater disposal 13 3 -compartment sink g[_Efe—ctrical hook-ups m Z <br />0 <br />13 Solid waste disposal O Food preparation U -Toilet and handwashing O 3 O <br />O Hot & Cold water for cleaning ["tore refrigerated food O Potable water n m n <br />0 Store dry food/supplies ®'Overnight parking 0 Vehicle wash D X <br />I,. hereby state that the information I have provided is current, true and N < m <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility M n <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the N 3 <br />commissary owner shall notify the EHD immediately. <br />Signature �..�Yna. Z'Q�! Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 <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 />