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SAW.JOAOUIN Environmental Health Department <br /> - --COUNTY--- <br /> GreatrPess brows heC2. <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—r— . C . Lie. Plate# Lj u C i Ll S <br /> Owner/Operator Name ` 2 <br /> Business Mailing Address w <br /> City - � StateZir Bus. Ph. U <br /> I, 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 discontifluedthe permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocatioand' en <br /> C'- �'z��� <br /> Signature Date <br /> 2. To be com leted by COMMISSA OWNER/OPERATOR <br /> Commissary Name j\n0 (' ci ' P ( - FA# <br /> Address CIZ,� '\U Bus. Phone I 73 C A '- 6 <br /> City a Zip,—.(aLj S� I Owner/Operator LU N N1yl lzf)� S/ N6, H <br /> Check all appropriate services provided: <br /> p'wastewater disposal I? 3-compartment sink El Electrical hook-ups <br /> IR Solid waste disposal EI Food preparation EI Toilet and handwashing <br /> Hot& Cold water for cleaning E1 Store refrigerated food ® Potable water <br /> [ Store dry food/supplies U Overnight parking 0 Vehicle wash <br /> I, Q i] Ud�Yi <br /> 12 9') 5 i N blh , 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 immediately. <br /> Signature "u.� �' Date l a�I h <br /> 3. To be complet6dby 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_sigov.org/ehd <br />