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SANAAQUIN Environmental HaaI��tt De arcra.nr <br />—COUNTY— <br />Greornesc _iro,,5 . T. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility s Caterer <br />Complete sections f 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 /VOrA) If ice ci'Ea m Lic. Plate# <br />Owner/Operator <br />Business Mailing Address / d X c n r o nr ► cf e .'t v <br />City6toc --b6iJ State CA Zip fOU a6 Bus. Ph.209-Y30 -/A 73 Alt. Ph. <br />o� �� jo hereby state that the above information is current, true and correct to <br />the be 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 />-- Lam„ - . e l . - n�ro. 2 �- 2 6 a <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary NameP c JC nV`i' o gr eRv�FA# <br />Address 341/.2 6 rn i Nz A Q+V'c_ _Bus. Phone aP °t2 �uiY —I l �tq <br />City STo Ck 9o.,r ZipM sao Owner/Operator 0 W <br />Check all appropriate services provided: 0 N <br />13 Wastewater disposal 0 3 -compartment sink dElectrical hook-ups m <br />Ci Solid waste disposal 0 Food preparation Toilet and handwashing Z 3 t <br />L'1 Hot &Cold water for cleaning tore refrigerated food iPotable water m <br />EI Store dry food/supplies Overnight parking D `Vehicle wash 40 D X t <br />hereby state that the information I have provided is current, true and C" ' <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility p R1 <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 the EHD immediately. <br />nate k1— '�X 1 <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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wvvw,sjgov.org/ehd <br />