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SAN J AQUIN Environmental Health Department <br /> --COUNTY-- <br /> u r c h. ,T- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility t 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 p <br /> Business Name 1ZC CCC/��d1��/�1 Oe=of Lic. Plate# <br /> Owner/Operator Name C !GE a <br /> Business Mailing Address �c��!`a ( ,9y1/'io1?-r 5 <br /> City�I d�✓ / i�tat Zipus. Pt�ryOZ(Y�" 22W. 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 st notify the EHD. Failure to notify this office may result in permit <br /> revocation a d-pen ties. <br /> Signat� <br /> /�GDate4 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name `��f� �(C� (�C��ys� FA# <br /> Address ,9,t�/79142,e gL.y® Bus. Phone AeY'.0 J^ t/co1 <br /> CitydjtJp2A 5�td Zip Owner/Operatorm.46 9647 Sr 1 � <br /> Check all appropriate services provided: <br /> ® Wastewater disposal 0 3-compartment sink 'aElectrical hook-ups <br /> p Solid waste disposal 15\Food preparation dR Toilet and handwashing <br /> 4� Hot& Cold water for cleaning S,Store refrigerated food EkPotable water <br /> 6�,Store dry food/supplies aOvernight parking IR Vehicle wash <br /> I, , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the. conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o ner hall notify the EHD immediately. <br /> Signature— Date <br /> 3. To be completed by the ENV <br /> II HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in S ti� l0.ttiS 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 /> \ 1U�d, a S T�✓l �( r ` <br /> REHS Signature �wLi ` 111 Date �O —2 <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 />