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: SAN JOAQUIN Environmental Health Department <br /> --COUNTY- <br /> - <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 com leted by APPLICANT <br /> Business Name'�-gc oS F_L Fv Go \ C Lia Plate# 4 U ,6.LF7Z <br /> Owner/Operator Name�Co� vs�o C�Cc��rwr ` oveL <br /> Business MailingAddress�� <br /> City 'T6Qcy StateCtfZip9 3� oy . Bus. Ph.(7-Oq)31%-y66Y Ait. Ph.(2z9)9iy-aY& <br /> I, 1"6ahc SO S In 4C1 GwV UL -, 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 /> Signatu _ Date_ ��oL�aU2� <br /> 2. To be completed by COMMISSARY O ER/OPERATOR <br /> ll �. <br /> Commissary Name FA# <br /> Address Bus. Phone <br /> CltyM Zip C�`7 O Owner perator <br /> Check all appropriate services provided: <br /> IP Wastewater disposal 'Ci 3-compartment sink t,1 Electrical hook-ups <br /> } Solid waste disposal ® Food preparation Lyr Toilet and handwashing <br /> Hot & Cold water for cleaning © Store refrigerated food Potable water <br /> °-) to dry food/s ies Overnight parking ''4 Vehicle wash <br /> hD/IlN%� l9 ry�nl�Gy" , 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 fail mply with the corlOftions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa owr shall-notify the. D immediately. <br /> Signatur Date V 02 — ;'-0 <br /> 3. To be completed by the ENV HEALTH 'urisdiction outside of San 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 209 454-0138 1 vwnv.Sjgov.org/end <br />