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SANJOAQUIN Environmental Health Department <br />—COUNTY - <br />9 rows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete. sections land 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed <br />by <br />APPLICANT <br />Business Name _Qj'dU)! <br />1 <br />ZCe'_ Ct'?A m <br />Lic. Plate# 9217O <br />Owner/Operator N <br />Business Mailing Address T{VL <br />City Scfprk4j) v-\ State' dip _f4" Bus. Ph.,�p9 �/6"135��-i Alt. Ph. -209 <br />r�rr- <br />I,�%icLr1 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 />?}�%-5 <br />Signature \l2" y- lGLivvi Date <br />1.2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name � l CYC N C�o __4 c E C' .:& S m FA#_ <br />3 <br />City ST (:)(KToeV' zip cy{ chs�o <br />Check all appropriate services provided: <br />❑ Wastewater disposal ❑ 3 -compartment sink <br />❑ Solid waste!disposal O Food preparation <br />❑ Hot & Cold water for cleaning GYStore refrigerated food <br />❑ Store dry food/supplies overnight parking <br />Phone 0\v-kZ- \-)\k9 <br />� to <br />A <br />9,flectrical hook-ups --1 N <br />[�I oilet and handwashing m <br />E3Potable water Z Z <br />❑ Vehicle wash D M <br />I, Y. hereby state that the information I have provided is current, true and W. D <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility N G <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the N 171 <br />commissary <br />��owner shall notify the EHD immediately. <br />Signature,) 7tM, J�'n.�Lr g' A Date <br />3. To be completed by the -ENV HEALTH jurisdiction outside of San Joaquin Go. <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 />