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"S FI N j 0[A0 U <br /> -----COUNTY--- <br /> COMMISSARY <br /> - --COUNTY---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 C-G4C�y'CGY0_i7 Lic. Plate# <br /> Owner/Operator Name (CC',Id(-:--Y(714 <br /> Business Mailing Address /0,79 ff)-/GA 0"/A -/ —1 e <br /> City ,Suck-low State_LLZip 20 Bus. Ph.AOy-9o5;io90 Alt. Ph. <br /> I,4i✓Cs— , 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 /> Signature Qj2�� Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 1 G � fry r �°=�� Q trlJry�IT_FA# <br /> Address 5 , A �-,p�,j4 (;sem Bus. Phone . <br /> City �-1-csc" " _Zip �C Zv U Owner/Operator �� �c <br /> Check all appropriate services provided: _/ <br /> Q Wastewater disposal 03-compartment sink EElectrical hook-ups <br /> KSolid waste disposal Food preparation &/Toilet and handwashing <br /> E:;K Hot & Cold water for cleaning '�Store refrigerated food Potable water <br /> �Storedryy�food/supplies Overnight parkinghicle wash <br /> I, "d 0 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 sha the EHD immediately. <br /> Signature �� Date S <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 /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />