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SAN JOAQUIN Environmental Health Department <br /> —COUNTY--- <br /> Greorn=s- prows re. <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 A �j --j C t Cyt G 'Z%—t Lic. Plate# S moi L1 <br /> Owner/Operator Name � <br /> Business Mailing Address J j 97 2 52A'> _i; o n In <br /> City Pj,fnt,e StateCC-Zip 95336 Bus. Ph.�3,0—�64,?,6�Alt. Ph. <br /> I, 44c-d- <br /> i A , hereby state that the above information is current, true and correct to <br /> thebebV& 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 /> SignatureDate <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name � -` C Y\ CV Cj U -j C Z_ CPG 0,0'7 FA# <br /> Address 3 t/1 1�), L Ni i of L R NNV 6 Bus. Phone " <br /> Cl <br /> City 7' o G K -- e n/ Zip � qs�o s Owner/Operator O/r perator c1 woV C X1 N :2 <br /> Check all appropriate services provided: 0 V n <br /> � 7C <br /> p Wastewater disposal E3 3-compartment sink electrical hook-ups X m Z <br /> E3 Solid waste disposal (] Food preparation -4 - G) <br /> toilet and handwashing 0 3 Q <br /> E3 Hot & Cold water for cleaning 0/ttore refrigerated food r1 Potable water ? Z n <br /> nmrm <br /> 0 Store dry food/supplies WOvernight parking 13 Vehicle wash D <br /> 1, hereby state that the information I have provided is current, true and to C <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility C m D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the C 3 <br /> commissary owner shall notify the EHD immediately. <br /> Signature Date tit — t/l— 'D�k <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joauin 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 />