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GePCJIb. <br /> SAN 10AQUIN Environmental Health Department <br /> " —COUNTY— <br /> c. Greatness g;c.is Len. <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 I nS P)Vc t�'i is j I ( Lic.Plate# L4 U Ikj SU-15 <br /> Owner/operator Name i tNI, I c_; [.o A,4 j Fa <br /> Business Mailing Address 2Q1U_- bpcsirm)N F=_ tea! F7_ <br /> City,St-ZCP, t Q K. State LAZip Cl. J Bus. PO 01I LA Alt. PhZCY(72 S f`]�q_S <br /> 1,1 [ kf-r� cim bF-9-1i 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. pp <br /> Signature i IMS Cwt 1 F!E� Date 5 �21Za 22 <br /> 2. To be completed by COMMISSARY <br /> //OWNER/OPERATOR <br /> Commissary Name /)cif!//_Uci/v �L l/Gs /1U FAr# <br /> Address /��� sG4ltih/Pf, � -(2'- Bus. Phone 1 <br /> City Ge e4' Zip Owner/Operator <br /> Check all appropriate services provided: <br /> ;3"Wastewater disposal 0 3-compartment sink K Electrical hook-ups <br /> qr Solid waste disposal Q Food preparation if Toilet and handwashing <br /> f4d Hot&Coldwater for cleaning 0 Store refrigerated food 7'Potable water <br /> E3 Store dry food/supplies Overnight parking pt vehicle wash <br /> I, 41le-r� / `IlC.;eub r z , hereby state that the information I have provided is current,true and <br /> correct to the best of my krpAledge,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 owner shall notify the E D i/mrpge iiately. <br /> Signature ��-fi.�1 //�Gc - Date <br /> A� <br /> 3. To be completed by the ENNPHEALTH jurisdiction outside.ofSan-Joaquin 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />