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��HOUTA i <br />I SAN�JOAQUIN Environmental Health Department <br />h'__: COUNTY-- <br />Greatness grows neve. <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 comqlpted,by APPLICANT <br />Business Name Q LNC' L �L� s � -- � —1;2 -tic �S Lic. Plate # <br />Owner/Operator Name _I L '4, > >'i;' 9, c <br />Business Mailing Address <br />City State C" Zip C'J S 2(c --Bus. P W'i 15 LS 01 Alt. P <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 discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature )U )\;,.j l 4 i% t C -:' L cc+D GUL'C , Date r `� -2c.-2 <br />L. <br />12. To be completed bx COMMISSARY OWNER/OPERATOR <br />A-1 _ . - _ r,).e ro n. 1 .tr t,b,C) <br />Comm <br />Il <br />_e <br />City <br />Owner/Operator. <br />Check all appropriate services provided: <br />0 ,6a-stewater disposal U�3--compartment sink <br />D�Solid waste disposal 13'Food preparation <br />Hod& Coldwaterfor cleaning "S re refrigerated food <br />EX SSttore dry food/supplies 'Overnight parking <br />i% <br />0/Electrical hook-ups <br />Toilet and handwashing <br />Cr'Potable water <br />UrVehicle wash <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 <br />operator fails to omply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary 9Vn, r all n ' //tt/h/HD immediately. % <br />Rinnati va ,Y ...-�ic�.,/�s7 mate / ,�/�_ <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 <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 />