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SAN ,JOAQUIN Environmental Health Department <br /> —COUNTY <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. Tobe.com leted'b APPLICANT <br /> Business Name /3 R c� c C ,Gce7 Lic. Plate# `�- <br /> Owner/Operator Name J , <br /> Business Mailing Address J j 97 9 SSP /-7 o n Ln <br /> City Man1GCCL StateCeLZip 9SJ3 (Bus. Ph..5--�v-W-V&-gP69Alt. Ph. Lf7�r=RZ�-G7GC� <br /> -exlf hereby state that the above information is current, true and correct to <br /> thebe4ftf my knowleerge 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 Date <br /> 2. To be completed'lby COMMISSARY OWNER/OPERATOR <br /> Commissary Name �' C K 0 9 C �_ C R G R cy'1 FA# <br /> Address M i rx 'L IR NIV t Bus. Phone QAy\4-- 1-1 �t 9 <br /> City S i o GK cnf' Zip C-0 0I-5_Z,!4-S7Owne Owner/Operator 0 u-v ay'En N :2 <br /> Check all appropriate services provided: p x <br /> 13 Wastewater disposal ❑ 3-compartment sink Wbectrical hook-ups m Z <br /> ® Solid waste disposal M Food preparation �oilet and handwashing p . <br /> © Hot & Cold water for cleaning It�tore refrigerated food 17 Potable water ? Z n <br /> comm <br /> • Store dry food/supplies WOvernight parking Cl Vehicle wash D X n <br /> hereby state that the information I have provided is current, true and 0 C - <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility G m D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the Cif +� <br /> commissary owner shall notify the EHD immediately. <br /> Signature � mcva r�/7 S'o 1-„ Date Ll <br /> 3. To be completed by the ENV HEALTH:jurisdiction outside of'San Joa inCo ' <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 />