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-COU N T Y----- <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 by APPLICANT <br /> Business Name ��GiLz rr fly` 14 r„r,� Lic. Plate# �2 <br /> Owner/Operator Name_� IV <br /> Business Mailing Address U c l on <br /> City State,_,�A Zip Bus. Ph. (S- , lc' 7,�) Alt. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> ��L T <br /> the besf 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/OPERATOR <br /> Commissary Name A 'I i;'� ' t"M FA# <br /> Address ' Zl; .- -F1 f E Bus. Phone l7irrj) Z.Zy 'Z <br /> City 1 , Zip Owner/Operator � ie_I 4cw/" _ <br /> Check all appropriate services provided: <br /> ErUastewater disposal compartment sink M-Erctrical hook-ups <br /> olid wash disposal Food preparation ! toilet and handwashing <br /> EVH-c & Col water for cleaning Wstore refrigerated food potable water <br /> Store dry food/supplies M-6vernight parking Ul­-Vehicle wash <br /> I A 7)—c,:, , hereby state that the information I have provided is current,true and <br /> correcf 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 shall notify the EHD immediately. <br /> Signature_ Date z ' 7 Z Z <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 />