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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 />Business Name • ' I o4e. 4,14 40e W6Q LL -C- Lic. Plate # <br />Owner/Operator <br />Business Mailing <br />City�f-o&IL+O StateLLZip `fSZ03 Bus. Ph.5TO -Zo-4-I 66°1 Alt. Ph. <br />I, j -e) ew+ 9+i dd , hereby state that the above information is current, true and correct to <br />the best Qj my knowledge and agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Enyironmen I Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the permi Eder mu tify the EHD. Failure to notify this office may result in permit <br />revocation a nalties. <br />10-12-21 <br />12. Tifb@�: ipleted by COMMISSARY OWNER/OPERATOR f 22� <br />Commissary Name tr661ta� P_y-,0\q QP°v�SiOyt S FA# Fid ©o'1, <br />Address_q3 43 Nor 'We4 Bus. Phone Z01 - '�3) -0323 <br />r.ity S+orl(.-i n v.) 7in OwnPr/OnPratnrY,'J�n.� 'V_':)4f0 <br />Check all appropriate services provided: <br />,ff Wastewater disposal Mr 3 -compartment sink <br />or Solid waste disposal P Food preparation <br />%3 Hot & Cold water for cleaning 0 Store refrigerated food <br />0 Electrical hook-ups <br />12 Toilet and handwashing <br />13 Potable water <br />P Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br />I, Z4%) �_ ��� � , 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 ft conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owper3A/(I noti immediately. <br />Signature ! `i IN)- Date <br />13. To be c6mDleted by the ENV HEALTH jurisdiction outside of San Joaouin 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 />