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SANJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grows hare. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete.sections f and 2. If your commissary is located outside of San Joaquin'County also complete section 3. <br /> 1 .1 . To corn Ieted by APPLICANT 1 <br /> Business Name�CICQ� �G� II Gornc1 rAy s Lic. Plate#5 � r <br /> ,�(1 <br /> Owner/Operator Name T(} jPG [4LIr+f/r1e,-7 �QYIC'�1'A f�SVInC,2.G' <br /> Business Mailing Address qq Is G. - 132 <br /> City _ 13 State�Zip �S.��Bus. Ph2'� A\Y17I�!26 It. Ph. <br /> I, 1 , 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. I <br /> Signature�{ylo ��(A jL/ne�� Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaarryNameC�G1 1f T� , �F/ G A�4# �CI '� 1 I i <br /> Address:I S • 1 Bus. Phone Z� 1 <br /> City _Zip Z Owner/Operator <br /> Check all appropriate services provided: <br /> p-Mtastewater disposal ELZ-compartment sink CrEffectrical hook-ups <br /> p -§b-lid waste disposal Er Food preparation I Toilet and handwashing <br /> p-Kot & Cold water for cleaning O-Store refrigerated food �0-f-rotable water <br /> a-S ore dry food/supplies Overnight parking ETVehicle wash <br /> I, I�An A /\, , 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 /> commissa neer shall otify the EHD imme ly. <br /> Signature Y/1 ' �� I0/�s � Date <br /> 3. To be corti'•_leted bthe`ENV HEA`LTH �dfill <br /> 'Yn;ohtside of3SanaJoajn ' o„ <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 />