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SAN JOAQUIN Environmental Health Department <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 S t S I CI N1 Gr& Uc.Plate# q uZ,5,7 7 7 <br /> Owner/Operator Name GugcizT '5elu&No <br /> Business Mailing Address 75/ R&IL t�f— VE <br /> citylO C)P state- A zip 33o Bus. Ph. 95e 2110 at.Ph. <br /> /^ <br /> I, l q 14BfRT 6-W AY1 d ,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 pen ties. <br /> SignaturL'� Date 7125-4c ZZ' <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name�,tl�lDit� Cg LE wts; Tf-&& �N7�R FA# <br /> Address 17(7S. 1Z f[6(b S7Bus. PhoneCj6t) 7 <br /> CitXCDC�CTO �ZipJJIL�Owner/Operator drF:5_71e?A1?6 <br /> Check all appropriate services provided: <br /> ($'wastewater disposal [5(3-compartment sink ErElectrical hook-ups <br /> tg solid waste disposal mood preparation [`Toilet and handwashing <br /> L5["Hot&Cold water for cleaning M16tore refrigerated food t3'�otable water <br /> 12 Store dry food/s�upplieCs� rt C�vemight parking Vehicle wash <br /> r I�r,V ,hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the Califomia Health&Safety Code requirements. Ifthe food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary own all n ti E immediately. 7// <br /> Signature ZM Date /tz�1022. <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San doa 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjg0v.org/ehd <br />