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-•rOln. GreOt I ' rte. Envir <br /> °amental Health Department <br /> Hess <br /> grow, here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facilit . <br /> Complete sections 1 and 2 Y Caterer <br /> • If your commissa <br /> 1 �- ry is located outside of San Joaquin County also complete section 3. <br /> o be com leted b <br /> APPLICANT ------ <br /> Business Name <br /> Owner/Operator Name -Lie.Plate# <br /> zt hc ( A5- <br /> Business Mailing Address `L 'I`t <br /> City �C L(DV�StateZip 115_('-�Bus. Ph. -7b Z3q I Alt. Ph. <br /> 4 Lb <br /> XKW�:-o'* 5 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 <br /> revocation and penalt' notify the EHD. Failure to notify this office may result in permit <br /> Signature <br /> Date. <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name___Z rri� - / I FA# <br /> Address S "e , Cr Bus. Phone <br /> Cit � <br /> Y a Zip Owner/Operator ��/�f <br /> Check all appropriate services provided: <br /> gj Wastewater disposal ❑ 3-compartment sink Or Electrical hook-ups <br /> a Solid waste disposal ❑ Food preparation 0 Toilet and handwashing <br /> 10 Hot&Cold water for cleaning ❑ Store refrigerated food [X Potable water <br /> ❑ Store dry <br /> f/ food/suppli/lies IX overnight parking ;1Vehicle wash <br /> I,— "e'Ll� z , hereby state that the information I have provided Is cuccent,tcue and <br /> correct to the best of my kqKledge,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 ify the HD i ediately. <br /> Signature Dat �� ��'-� <br /> 3. To be completed by the E HEAL, w <br /> c; ;rn outside of San 3oa Co. <br /> The commissary is located in i6County. The above food facifity meets the <br /> commissary requirements in California Health & Safety Co-e. The above checked services are available at kh, <br /> 9bove commissary. Please notify EHD if the status of th= -aerating permit changes. <br /> FHS Signature Date <br /> "^nAvenuel Stockton, mia 952051 T 209468-34201 F 209 <br />