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SANsJOAQUIN Environmental Health Department <br /> J& -COUNTY— <br /> r+ate` 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. To be com leted b .APPLIC,." TIM <br /> L� �A9�O <br /> Business Name Lic. Plate#_-/� /YI S` <br /> Owner/Operator Name <br /> Business Mailing Addressi <br /> City '/ /'' State&_Zip 0� . Bus. PhAd?-/,70- yf7fAlt. Ph. <br /> 1, Elly! 6. 5vf6 , 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�aand penalties. <br /> Signature Gyxi A1CCltk--r2 Sado Date 0,2 P- <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Nam FA# <br /> Address—e Bus. PhonegrnlO? /�-/�S7p <br /> City Zip y5d9� Owner/Operator ll' �u/I r p}f <br /> Check all appropriate services provided: <br /> M Wastewater disposal 0 3-compartment sink M Electrical hook-ups <br /> Ck Solid waste disposal E3 Food preparation 1I Toilet and handwashing <br /> 11 Hot & Cold water for cleaning 17 Store refrigerated food ® Potable water <br /> 13 1 <br /> Sto dry food/supplies M Overnight parking ki Vehicle wash <br /> I. AtMl'k I RN,4100 z , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and is the California Health&Safety Code requirements. If the food facility <br /> operator fails mply with the cond" s of this agreement, or if this agreement is modified or cancelled, the <br /> commissar/o shall notify the ediately. <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 952051 T 209 468.34201 F 209 464-0138 1 www.sjgov.org/ehd <br />