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SAN JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greotness 91-01'.; her'. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility a Caterer <br /> Complete sections f 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 Z�� f� s 1�L— Lic.Plate# <br /> Ownbr/Operator Name C <br /> Business Mailing Address -202—(- <br /> ,z, S U /\JA <br /> City State CAzip X151%ZBus. Ph. Alt. Ph. <br /> I, `?(fid /'1. Si G�/> tT�—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 /> and penalties. <br /> Signature <br /> —' �� – Date � <br /> ZZ <br /> 2. To be com' leted b .COMMISSARY OWNER/OPERATORI <br /> CCommissary Name Gl FA# <br /> Address d Bus. Phone 0 a– <br /> City h— Zip S OS Owner/Operator T�• LA �1 <br /> Check all appropriate services provided: U <br /> Ig Wastewater disposal Ed 3-compartment sink M Electrical hook-ups <br /> M Solid waste disposal Q Food preparation Elf Toilet and handwashing <br /> 23 Hot&Cold water for cleaning ❑ Store refrigerated food 19 Potable water <br /> 13 Sre dry,food/supplies M Overnight parking E!J Vehicle wash <br /> 11 14,,All 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-oo ply with the co itions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary notify4hfEHD immediately. <br /> Signature r"<i' ---� Date - a0 <br /> 3. To be corn leted b 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 />