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SAN JOAQUIN Environmental Health Department <br /> " ISI —COUNTY <br /> v,ectness grows here. <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 NameS�/iTl G.eIArn Lic. Plate# 7G SJ2-(-2,k <br /> Owner/Operator Name z4g-&I.t� 5-,9 <br /> Business Mailing Address 2072- <br /> City. <br /> o City State_,,�4 Zip i Bus. Ph. i-RyR,111 r Alt. Ph. <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 <br /> Signature *°z Date 03,12-�Zo2 2- <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name P i C M Y1/ CIO _1 c s CAG ACO FA# <br /> Address 30ia i�, WA24L� Bus. Phone `1,-01^ <br /> c ottnP_n �tG _ <br /> City C'To cK oh/ Zip 4 aSlot Owher/operator o t--Iy^p Nt,,t <br /> Check all appropriate services provided: 0 � <br /> 13Wastewater disposal ❑ 3-compartment sink electrical hook-ups M Z <br /> [3 Solid waste disposal ❑ Food preparation �'toilet and handwashing <br /> � • G) <br /> O <br /> E3Hot&Cold water for cleaning Pd-"Store refrigerated food 13Potable water ? Z <br /> n <br /> [3 Store dry food/supplies fia-dvernight parking [3 Vehicle wash y X m <br /> I, hereby state that the information I have provided is current,true and Cn D X <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility f� Mm <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the 0 IT1 n <br /> commissary owner shall notify the EHD/immediately. �+ <br /> Signature )��f.> , ��. ,d� s, ;lr Date <br /> 3. To be completed by 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.sjgov.org/ehd <br />