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SAN JOAQUIN Environmental Health Department <br />----COUNTY-- <br />Greornes, grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o 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 <br />Owner/Operator <br />Plate <br />Business Mailing Address 15 -) cJ Ts� Ufi <br />City �n StateC"ZipCY53 3013us. Ph. Q�Oc� kX 3 It. Ph. 3),U 1 6 5 '-1 7 <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. n <br />Signature I Ute`"�� Date b 1S f _D- <br />1 2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name T � C Y\ r✓ q o �JC f MG t1 r1 FA# <br />Address ILAI'A E m ial-ER A VE Bus. Phone <br />City S'i e CK-ni-'/ Zip eA of Owner/Operator vw N`R y Z <br />Check all appropriate services provided: O-4 c <br />E3 Wastewater disposal a 3 -compartment sink Qd" Electrical hook-ups n N Z <br />a Solid waste disposal © Food preparation Filet and handwashing m O <br />E3 Hot & Cold water for cleaning Pd'Store refrigerated food a Potable water Z Z O <br />a &' o Store dry food/supplies Overnight parking Vehicle wash y x m <br />I, hereby state that the information I have provided is current, true and D <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility N MM <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the Ch' 3 <br />commissary owner shall notify the EHD immediately. <br />Signature , sl Date S - S Wk <br />3. To be completed by the ENV HEALTH iurisdiction outside of San Joaauin 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />PK052-7i%-7 <br />