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SAN JOAQUIN Environmental Health Department <br />— COUNTY— <br />Cref!M"s5 graws herr, <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />Complete sections f 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 C, SrNr,li 1CI_ r g:,a#)/1 Lic.Plate# �t�4tSGx� <br />Owner/Operator Name C' AMSOLI RAL- S1644 <br />Business Mailing Address (4,6f2_ SAlup prt'r-A2 C)G <br />City Lone StateCR Zip!jszR('N Bus. Ph. Za4 Alt. Ph. <br />I, Gmcytt»brf= PoRt- Suwh lk , 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 />911. <br />2. To be completed b` COMMISSARY OWNER/OPERATOR <br />Commissary Name f i Cly !V G 0 m FA# <br />Address_3 N fl� L'. nr i ey- R Bus. Phone gaol- Q VVkf - /-I Ug <br />Owner/Operator. <br />Check all appropriate services provided: <br />p Wastewater disposal D 3 -compartment sink <br />E] Solid waste disposal <br />O Hot & Coldwater for cleaning <br />0 Store dry food/supplies <br />❑ Food preparation <br />AA Store refrigerated food <br />�M Overnight parking <br />'*t3 Electrical hook-ups <br />Toilet and handwashing <br />❑ Potable water <br />(3 Vehicle wash <br />iy <br />I, hereby state that the information I have provided is current, true and 0 <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility N <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, thea <br />commissary owner shall notify the EHD immediately. <br />Signature , 2�0e .C' ,/ Date <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 />