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- SAN JOQQUIN Environmental Health Department <br /> COUNTY- <br /> - -s ,n- <br /> ^`" Greotr,ass grows here. <br /> LIF�4" <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections I 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 4Er1114 uj� A.yn ZIA�C .V, Lic. Plate#�L_SS RO4 � <br /> Owner/Operator Name <br /> Business Mailing Address R'b 3 <br /> City rJ6,71r ON State,,-,4 Zip. Bus. Ph. Alt. <br /> I D tiler M 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/g/epal ' s. <br /> Signature 1 / ` Date <br /> 2. To be completed b/ COMMISSARY //OWNER/OPERATOR <br /> Commissary Name_ C�D�If3/�SC i1 !/ FA# <br /> Address / /f� Sr �GiG�4fTCis J S/ Bus. Phone ret -V l <br /> City Lai/ Zip r/ Owner/Operator �/ /kr <br /> Check all appropriate services provided: <br /> Wastewater disposal O 3-compartment sink I'Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation rfToiiet and handwashing <br /> Vf Hot & Cold water for cleaning ❑ Store refrigerated food d Potable water <br /> ❑ Store dry food/supplies Overnight parking Vehicle wash <br /> I, &eA4 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 owner shat notify t e EH fimediately. r <br /> Signature Date J` �k 04 <br /> 3. To be com leted by the V 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 Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />