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SAKdOAQUIN Environmental Health Department <br /> 1.- ":I' —COUNTY— <br /> .. <br /> �rdf O� <br /> ` Greotness 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 . To be completed by APPLICANT <br /> Business Name '�� 7h TCl C(2?a r11 Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Addressl� 0, vwn t 7 NL <br /> City CfioCk'o State Zip�h"� (� Bus. Ph.t�D9 �/6/Alt. Ph. c) 7{� l <br /> I, jULn - C'- fe JZ,1 " 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 ) I}2P i� -� �e1GLc..c>vt Date <br /> 1.2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name C Q&bi m FA# <br /> Address 3y !A 6 m ti1VC_Q S,V'G Bus. Phone 0\vkZ- \-m9 <br /> City S;0 ctcToo✓ Zip co OwWe-r/Operator <br /> Check all appropriate services provided: -_i W n <br /> O <br /> C) Wastewater disposal O 3-compartment sink 1 €lectrical hook-ups <br /> � N Z <br /> p Solid waste'idisposal O Food preparation [Vleoilet and handwashing -1 In G) <br /> o <br /> O Hot & Cold water for cleaning Cd,,Store refrigerated food O Potable water Z Z <br /> 0 Store dry food/supplies 10,t'overnight parking O Vehicle wash D M M <br /> I, hereby state that the information I have provided is current, true and (p„D n <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility NJ C m <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the O M 'IN <br /> commissary owner shall notify the EHD immediately. 3 <br /> Signature Date <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 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 />