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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 />Business Name ( ,:•i Z L/��C <br />Fns �% <br />Lic. Plate # &S,7 / d5 <br />Owner/Operator Name <br />er-iLG <br />Business Mailing Address L-- <br />City,STn_r�T/).y StateCJV Zip YS:,)cS-Bus. Ph�C 9i�ci'/-�7J 7 Alt. Ph. �d� ��� • <br />I, , 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 />Signature Date <br />2. To be completed by COMMISSARY OWNER/OPERATORAW <br />Commissary Name Pic K rs' Cv0 /CE'C/C--L-M <br />1. <br />Phone 2ei-`3_4,?-174Y <br />zcS <br />Check all appropriate services provided: <br />E3 Wastewater disposal 0 3 -compartment sink <br />0 Solid waste disposal <br />O Hot & Coldwater for cleaning <br />0 Store dry food/supplies <br />0 Food preparation <br />V-Stbre refrigerated food <br />93'E'lectrical hook-ups <br />Ell-T611'at and handwashing <br />0 Potable water <br />13'Overnight parking 0 Vehicle wash 0 <br />hereby state that the information I have provided is current, true and 0 <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility Ch <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. <br />Signature Date / •- 3 - `�, <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 <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 />NZ <br />m0 <br />30 <br />