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SANdOAQUIN Environmental Health Department <br /> —COUNTY-- <br /> Greatness grows e. <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 com leted by APPLICANT <br /> Business Name l_d-(Grua� "T-CM,iz0 Ty(_xx Lic. Plate# <br /> Owner/Operator NamejaNIUVI'1V! pYYP� i 't 7CL <br /> Business Mailing Address i r <br /> CijaW> f —State C zi 7-641 t Bus. Ph. -5TO"b`f�b�It. Ph.7 Oq - b �O -)(Ll6(a <br /> I, gni ua� � hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to ilize 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 /> c� - <br /> Signature [ Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Y bZ -_reLl. FA# <br /> Address (o;�/i C Cyv-n4,�k . c Bus. Phone 2 `] -77�l <br /> city- 1-0 pj zip - &Owner/Operator 4U*r N a ry d,4*— <br /> Check all appropriate services provided: <br /> Mlastewater disposal 13-:�<Cocmpartment sink WIffi//ec''trical hook-ups <br /> Q-golid waste disposal L11 ood preparation L�foilet and handwashing <br /> ED 4 of&Cold water for cleaning G}--g-tore refrigerated food wootabie water <br /> U !`tore dry food/supplies 06vernight parking i7Kehicle wash <br /> l �eW 04 .5 564r hereby state that the information I 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 shall notify the EHD immediately. <br /> Signature <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 />