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SAN JOAQUIN Environmental Health Department <br /> -COUNTY- <br /> Greatness 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 <br /> pl <br /> Business Name G 4 Mcf Lic. Plate# 114 FS3 Ci `Y <br /> Owner/Operator Name A/1't 7 V aSAUCCA & lRY19A <br /> Business Mailing Address 3S 5 y ToO jnF t <br /> City mO Mn State Zip Bus. PC o� X9-75 7Alt. Ph. <br /> I;N(TZ A d7 :RIVA —, 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 h7;011-W <br /> ust notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. C >���1Signature-Xrr-lr, F� r��r� S�U)Q Date o 2 <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> CommissaryName QNI0N e_E037_FAFA# <br /> Address12175 . uP4l6Ili S-r, Bus. Phone(-;O Q J 6 <br /> City G fibc,�Tjk� CIA Zip 9,x.2 1_�- L Owner/Operator <br /> Check all appropriate services provided: <br /> W'V6stewater disposal -compartment sink ®'Electrical hook-ups <br /> +/?"Solid waste disposal 131F�ood preparation t1'I Loilet and handwashing <br /> Ef HHot& Cold water for cleaning 0"Store refrigerated food ��otable water <br /> Q Storepdryry food/ lies ®�vemaight parking vehicle wash <br /> I, A/ I �ftiltyx 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 agr�ement is modified or cancelled, the <br /> commissary owner shall y ify�$�gEti immediately. �/Z� <br /> Signature__i1 l Date <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 />