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` SQNJQQQUIN Environmental Health Department <br /> —COU NTY- <br /> - Greotness 9rcws 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 /> Business Name/,/�' Lic.Plate#Z//" 6" 7 G/ Z_ <br /> �-t <br /> Owner/Operator Name p /"e'li ;)A(A <br /> Business Mailing Address �G;�j !tl C-EGA 'iL1/9-- <br /> City !i c e Z StateCf�Zip `9/ Z Bus. PhE 2G t. 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. % f <br /> Signature / 1::�D 200A r1-- Date A/ '2 <br /> i <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> i <br /> CommissaryName ='� /I � s �7/ pp,# <br /> Address z�IYo S A, w po.r4 Cn� Bus. Phone -15-4 <br /> City S)-;0CAL. A Zip MOwner/Operator 5 12-i/j ic, <br /> Check all appropriate services provided:: <br /> Wastewater disposal E(3-compartment sink ErElectrical hook-ups <br /> Er/Solid waste disposal Q'Food preparation E'l�Toilet and handwashing <br /> Licit &Cold water for cleaning [ /Store refrigerated food Ef Potable water <br /> ff'store dry food/supplies p Overnight parking Er'Vehicle wash <br /> I, R 'm-s LO , 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 t e EHD immediately. <br /> Signatur _� 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.sigov.org/ehd <br />