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'SAN JOAQUIN EnvrPorttmenW Heafth Department <br /> - —COUNTY---- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ,, Caterer <br /> Complete sections f 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 C-'Gc��P_Y��J Lic. Plate# 2[/d?17V <br /> Owner/Operator Name ¢4i%Gx- G Gk/0((E �( b1 <br /> Business Mailing Address <br /> City_5 Loc k&Joc_, State_�AZip C(s-z0 ry Bus. Ph. °�-985 e/ 90 Alt. Ph. <br /> 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 Califomia 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 /> Signature Q Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Namenn FA# <br /> Address Z `a lt <br /> �O 5 , dC%Gur4- tAa,,a Bus. Phone _Z ci - — 5166 <br /> City Zip qC 2-v L5 Owner/Operatois n <br /> Check all appropriate services provided: <br /> R'Wastewater disposal E,3-compartment sink MI/Electrical hook-ups <br /> [Solid waste disposal LiFood preparation Ir5✓Toilet and handwashing <br /> EX Hot& Cold water for cleaning 2'Store refrigerated food T/Potable water <br /> Ir Store dry food/supplies Overnight parking hicle wash <br /> "L ca hereby state that the information I have provided is current, true and <br /> correct to the b st 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 sh the EHD immediately. , <br /> Signature Date S f / <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />