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CpG JI:.i - <br />SANJOAQUIN 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. Tolpe cqm <br />. leted�li <br />AFPL+ICANT _ <br />Business Name <br />C H a P <br />e s -i-w COS <br />Q <br />Lic. Plate #4 YOU 2 <br />Owner/Operator Na <br />Ph. <br />I,—e�i2 �(k(� 7 , 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 />1'2. To be com6leted16v COMMISSARY OWNER/OPERATOR <br />CommissaryNameG, I I YvtY11 M 4'Arft r t" 5V091 `l FA# <br />Address Arrpvr,/— r,.<- ;z Bus. Phone 7V <br />City J -y Ck Zip QCZ& 6 Owner/OperatorA.Ae%. <br />Check all appropriate services provided: / <br />EWastewater disposal EVS-compartment sink a Electrical hook-ups <br />[}Solid waste disposal L;l�Food preparation 12'Toilet and handwashing <br />EYHot & Cold water for cleaning Store refrigerated food Cd/Potable water <br />CLStore dry food/supplies d Overnight parking I:/Vehicle wash <br />I,iF�S �.� loty 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. , - t , <br />:3: To be cam 1etedlb tFie,ENV HEALTHI'uris-diction 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 />