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SAN 10AQUIN Environmental Health Department <br />-COUNTY—- <br />Grearn•_ss grows +ier >. <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 <br />Business Name A c,y ' 5 ccs S M q 2a � I G 17 Ira I em k(? Lic. Plate <br />Owner/Operator Name Vca ) e v\ 4 r vt Go V1 2 a I< <br />Business Mailing Address 1 `I f f- y C r I \nra Y" <br />City S kocYN koh State C4 -Zip cf.5 06 Bus. Ph 2c)71; S 18- 6!a5 Alt. Ph. <br />I, , 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 />Signature VQ 1 C" 4 C o zc / Date <br />12. To be completed by COMMISSARY OWNER/OPERATOR I <br />ri <br />Commissary Name_L <br />Phone L1— lye <br />City Zip�1�_owner/Operator <br />Check all appropriate services provided: <br />Wastewater disposal (( 3 -compartment sink I: Electrical hook-ups <br />{� Solid waste disposal 14 Food preparation $( Toilet and handwashing <br />Hot & Cold water for cleaning Ed Store refrigerated food Or Potable water <br />$a Store dry food/supplies 0 Overnight parking Ig Vehicle wash <br />I, �e�-e 'L�,h i c) , 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 />M_f l <br />w / /7- <br />3. <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 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 />