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Health Department <br /> SANsJOAQUIN Environmer COUNTY-91.11, t1e 1 <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility♦ Caterer date section 3. <br /> Complete sections land 2 If your commissary is located olds/de of San Joaqulr'Co"r'I y also romF <br /> "I.-To be completed by APPLICANT I fir,a S <br /> Business Name ¢_IS CC75 E\ / <br /> —T l'?�CJ �tn.l _Lia Plate# <br /> Owner/Operator Name G rT f t-e W <br /> Business Mailing Address '�"t t S� U <br /> j h.— <br /> City S' (-'-fp J State/GQ-Zip�/Q.Bus. <br /> I a.14 k a2) ,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. Y the use Of the <br /> commissary is discontinued,the permit holder must notify the EHD. Failure to notify this office may result innp <br /> it <br /> revocation an enalties. / t <br /> Signature I` t7 Date_ <br /> o be completed by COMMISSARY OWNER/OPERATOR <br /> FA# <br /> Commissary Name ?- ,°i how H �su+�Y � B3 =k,41Address (070 �S Spy=a+'r'�+� Sk 9579a Bus. Phone 209) oZ �l - <br /> City L^17r Zip r'ISZS'U Owner/Operator Ifll c J2 dl <br /> Check all appropriate services provided <br /> � <br /> L9"3-compartment sink m'Electrical hook-ups <br /> Wastewater disposal L <br /> Solid waste disposal <br /> O Food preparation C9' I oilet and handwashing <br /> 0�� // Store refrigerated food [9 Potable water <br /> p'Hot& Cold water for cleaning g <br /> Store dry food/supplies <br /> Overnight parking ® vehicle wash <br /> I <br /> if), 1rGu4( /�/�,.tc� , hereby state that the information I have provided Is current,true and <br /> ety Code requirements. <br /> fadilitV <br /> correct to the best of m;_ <br /> y kn ih lthegcondtionseoft this agreement California aorhif th this agreement is modified or cathe nceled, the <br /> operator fails to comply <br /> commissary owner shall notify the EHD immediately. Date <br /> Signature �` <br /> 3 To be com leted b t the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> County. The above food faahty meets the <br /> The commissary is located in <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> bove commissary. Please notify EHD if the status of their operating permit changes. <br /> Date <br /> REHS Signature <br /> 68 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />