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i <br /> SAN OAQUIN Environmental Health Department <br /> I+L'd —COUNTY <br /> Greatness 9ron <br /> _ COMMISSARY AGREEMENT <br /> y Mobile Food Facility • Caterer <br /> Complete sections 1 and 2. //your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> ,in � <br /> Business Name Y / G /n iL FL) 0 ✓ Lic. Plate# 422 v�120 <br /> Owner/Operator Name t V c <br /> Business Mailing Address? O 50� f 11 Scr c/Zel n w f <br /> City 51xlLFc State (f Zip 4 SZ4JBus. Ph.(h/(15771-Gf 'Alt. Ph. <br /> I, G✓'O A%,/4 , 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 /> ;y revocation and pert I Vis. <br /> Signature 5 Date /Z/2ZZ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name A-z t f-c.!} FA# <br /> Address / 11 Sac.l`i'/�j gus. Phone ZZk-5�3 ? e( <br /> a. City tr c!/( . Zip -(47q0 Owner/Operator.--(x <br /> Check all appropriate services provided: <br /> Q Wastewater disposal q 3-compartment sink Electrical hook-ups <br /> 0 Solid waste disposal 0 Food preparation P Toilet and handwashing <br /> ® Hot& Cold water for cleaning ® Store refrigerated food 13 Potable water <br /> ¢t Store dry food/supplies 0 Overnight parking M'Vehicle wash <br /> I, RL- 9cr ite(Ee 6L404 , 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 shall notify the EHD immediatelyy. <br /> Signature �� �/ Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 /> I <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 />