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SAN.JOAQUIN Environmental Health Department <br /> z z, <br /> L-J" 4` —COUNTY— <br /> Greatness <br /> COUNTY— <br /> Greatness grows here. <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 -Zr- 6:- .CCc- ic.Plate# / �J <br /> Owner/Operator Name— Gt C l/GY/! la/J <br /> Business Mailing Address 30`2(,0 (.e9�W'V?701InnS,,��,,�� S <br /> city�y�+�N�i�Stat�,Zip us. PYCd�ye54/- �. 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_amt notify the EHD. Failure to notify this office may result in permit <br /> revocations pen ties. <br /> SignatryrE' / Date <br /> c <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Namemlj.-) C,) 2tolle &Ce nCe,,jw/ FA# <br /> Addres9Cyo Bus. Phone 9'0?- 0 Jam= tA1,2I <br /> Ci tyy f Op t� 0 Zip _Owner/Operator D144 9 A1eS• 94" <br /> Check all appropriate services provided: <br /> ❑ Wastewater disposal ❑ 3-compartment sink 1151�Electrical hook-ups <br /> ❑ Solid waste disposal $Food preparation q Toilet and handwashing <br /> 4� Hot& Cold water for cleaning 8,Store refrigerated food B-f�otable water <br /> $Store dry food/supplies Q Overnight parking ®. 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... hall notify the EHD immediately. <br /> Signature /// s 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 Is l�v,--& 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 /> , d, a S+ t {y lJ l 1�D <br /> REHS Signature U.1.i C rl✓n. G ate (O --2- <br /> 1868 <br /> 21868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />