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SAN JOAQUIN Environmental Health Department <br /> —COUNTY— <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 o m G ftu t TS' Lic. Plate# I1 C/5/ 7 <br /> Owner/Operator Name eCTi20 nP a P 6 8 L b <br /> Business Mailing Address 33 D S . S l ERRA N6114dol <br /> City-570CKT&(0, State G-AZip95.,ZC5 Bus. Ph.(211?)666-77yaAlt. Ph. <br /> I, PC-Ttt6f i/} r,4�L�) , 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. FFA /I ,�C,2 2- <br /> Signature P F p Date �T <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Q 1�(110 N e-8 I L- 006 TRLVV_ C Ct;�n�lCtp-FA# <br /> Address 17(.1 S tek Lo AI ST-. Bus. Phone q(91aaq� 51 <br /> CityS (k1U Cfl Zip 95.266 Owner/Operator fi ff 1 !kADy <br /> Check all appropriate services provided: <br /> (:jj'5Vastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> CWSolid waste disposal ❑ Food preparation qdToilet and handwashing <br /> ❑ Hot& Cold water for cleaning ❑ Store refrigerated food l?Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> �t <br /> I, [) K-T- 71 K 0,60 , hereby state that the information I have provided is current,true and <br /> correct to the best 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 hall otify the EH immediately. <br /> Signature l7/z z Date a� <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 />