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F SANAOAQUIN Environmental Health Department <br />_._—COUNTY-- <br />Gscetness 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 />I. To be completed by APPLICANT 7771 <br />Business Name G ��i i� 7—fi 4P u t: a 1 fi Lic. Plate # 71) la r-6-6 3 <br />Owner/Operator Name S/NG d (3 UR/Q 13,9L <br />Business Mailing Address '/G// % K W " 5T6 r /f!/b. <br />CityS'r L kp%g State Zip *SZc b Bus. � O 6 J � - / 8'6 Q Alt. Ph. <br />I, 5 //v G N 6 tf K 1 6L , 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 penalties. / <br />2. To be.com leted by COMMISSARY OWNER/OPERATOR . <br />Commissary Name G(/L/(in/V LG7(�R12'(x (ftU� K (' L�rLt <br />Address./ 7/ 7S. lllet edt( S% • Bus. <br />City QcKTo4f, . —/d Zip ,;,ZO L Owner/Operat( <br />Check all appropriate services provided: <br />ni/Wastewater disposal 13/3 -compartment sink 01"Electrical hook-ups <br />M//Solid waste disposal ©'Food preparation Cr' 'let and handwashing <br />CJ/Hot & Cold water for cleaning /SStore refrigerated food C Potable water <br />M Sttoreeddry food/supplies ® Overnight parking U° Vehicle wash <br />I, /7 f. I I 1 71 U 6) , 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 own#gshalLpptify thwEHD immediately. <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. Hazekon Avenue I Stockton, Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />