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SKJOAQUIN Environmental Health Department <br />—COUNTY-- <br />Greatness 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 Name db )q 6- H -��/� 1�^ 7'r1 �� �/ / Lic. Plate # (p <br />Owner/Operator Name �J6t i` <br />Business Mailing Address a L4-3 D A I lq L/C) I- e <br />City.S %OCK7erAl State_4 Zips /7- Bus. Ph.��drU 3 I r'4. Ph. E <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 />2 <br />Signature /,// � cld Date)-3— 2,3 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name � � CSC n/ C u 9 C <` C9,C�M FA# <br />Address 3`/I'_4 { m; prP Q EjTC Bus. Phone `)o ol- y; \-i yv, <br />City -S"rc Ck -re,✓ Zip cA cks`aoS Ownt�;/_Operator oL-IW6 <br />N <br />Check all appropriate services provided: - W n <br />❑ Wastew er disposal ❑ 3-compartment sink electrical hook-ups 0 N Z <br />[3 Solid wast' disposal ❑ Food preparation Qe foilet and handwashing -i In Gi <br />00 <br />❑ Hot & Cold water for cleaning ❑'Store refrigerated food 13Potable water Z Z <br />n <br />❑ Store dry food/supplies O'overnight parking ❑ Vehicle wash D M m <br />I, hereby state that the information I have provided is current, true andto D <br />correctTo the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facilitz C m <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the0 :n <br />commissary owner shall notify the EHD immediately. 3 <br />Signature Date I 3 - '�I:Y <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 />