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SAN 10AQUIN Environmental Health Department <br />--COUNTY— <br />`n,.nv��-rr;tnsc 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`S <br />Business Name /SCI t )l (� � <br />Owner/Operator Name v 2 '� <br />Business Mailing Address , 3) I cj <br />Plate #� AO L of q <br />City -5 1(f )M -StatELZip 5a Bus Ph.(�g1 � ti30I Alt. Ph.0,A) 19 <br />1, (a„Q,r\� (�W� �� o 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 completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName P k- Wgo 4cr- C �RE )A cn FA# <br />Address 39k'), E c9znr'),71nr C- R AVC Bus. Phone 2nq (21 \A <br />City 17-o ZiprA of S2R S'Owne O/r perator (j) <br />w <br />Check all appropriate services provided: 00 P. <br />D Wastewater disposal 13 3 -compartment sink W,9ectrical hook-ups x N <br />M <br />q Solid waste disposal E3 Food preparation 91nToilet and handwashing 0 <br />K <br />Q Hot & Cold water for cleaning Store refrigerated food D Potable water ? Z <br />D Store dry food/supplies 111 -Overnight parking 13 Vehicle wash y � <br />I, hereby state that the information I have provided is current, true and N D <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility N f<rl <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 Date <br />3. To be completed by the ENV HEALTH iurisdiction 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 www.sjgov.org/ehd <br />'0 <br />r <br />Z <br />C <br />C <br />rr <br />C7 <br />R1 <br />3 <br />