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SAN JOAQUIN Environmental Health Department <br />—C, %LINTY— <br />. �ir'eetn, ss 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 SUNS i lc-.E«���� Lic. Plate# <br />Owner/Operator Name /I`L�/�w � <br />Business Mailing Address )-7d-S GT <br />4��la Bus. Ph. fir'% Alt. Ph. <br />AIW A7 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 penal4s. <br />M.: <br />12. To be comDleted by COMMISSARY OWNER/OPERATOR I <br />Commissary Name P 1 CIS l✓ q0 tJ c L ckg d w FA# <br />3 Lf 19 E' <br />Phone C4 gr - 11 u q <br />City S'To Cr-rojV Zip !E�f A r2oS Ov✓ner/Operato <br />Check all appropriate services provided: <br />E3 Wastewater disposal ❑ 3 -compartment sink <br />p Solid waste disposal ❑ Food preparation <br />❑ Hot & Cold water for cleaning [Store refrigerated food <br />❑ Store dry food/supplies [;.Overnight parking <br />v c✓ /V <br />O <br />%-Electrical hook-ups <br />n <br />lid''Foilet and handwashing <br />❑ <br />® Potable water <br />Z <br />® Vehicle wash n <br />D <br />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 IV <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 � ztno- ., Date <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 <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />V n <br />N Z <br />m <br />30 <br />Z <br />n <br />Mm <br />Dn <br />m> <br />3 <br />