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SAN 10AQUIN Environmental Health Department <br />—COUNTY— <br />c.;_`' Greatness ,nro�:s [;erg. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility t Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3- <br />11. To be completed by APPLICANT 1 <br />Business Name g/f Cc' F40VI L-- Lic.Plate# <br />Owner/Operator Name r6g ill A h4 b&Z <br />Business Mailing Address (t— ,S . 6L -104E Sf: <br />City TC�K Stat Of Zip_ 5)k6 Bus. Ph4E y 1j�i—q It. Ph. <br />I, LF- W o V-0 / a'74t//iy". Eby 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 permi r must ryojify the EHD. Failure to notify this office may result in permit <br />revocation and rrafialties. <br />12. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName UdION d 1f7 -6P I ISG IRuck C6aYEK FA# <br />Address 1717 S. akf( tit S7- Bus. PhonezG 9/ ( C. <br />City.5Tyc-KT66.F CA Zip `?S.ZG 6 Owner/Operator/�/Q% RRDd <br />Check all appropriate services provided: <br />M4ftstewater disposal e3 -compartment sink <br />p solid waste disposal eFood preparation <br />'Electrical hook-ups <br />®'Toilet and handwashing <br />1121 -'Hot & Cold water for cleaning Store refrigerated food 113,f3otable water <br />Er Store dryfood/ plies S'overnight parking M -'Vehicle wash <br />I, �k 7—l (R If D ln� , 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 modi ed or cancelled, the <br />commissary owners II n H immediately. <br />/1y/,�� 2 <br />Sinnafirre � // /� Date // 2 I <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 <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 />