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SAN JOAQUIN Environmental Health Department <br /> - COUNTY- <br /> 6t1QtT)eSS grJwS here <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 <br /> /APPLICANT / <br /> Business Name � � co4ee Crj Lic. Plate# TTS S 6 �G <br /> Owner/Operator Name T i'Uk "" e <br /> Business Mailing Address_ 2 E q3 inoi1kr -d Gy,�— <br /> City I E (d )State 64-Zjp_22tiZ Bus. Ph. Alt. Ph. <br /> I , hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to tilize m approved commissary in accordance with California Health & <br /> Safety Code, and San Joa n Coun nviro ental Health Department (EHD) requirements. If the use of the <br /> commissary is disc inu ,the p hol r ust notify the EHD. Failure to notify this office may result in permit <br /> revocation and p Itie . <br /> Signature Date_Lal 7 <br /> 2. To completed leted b COMMISSARY OWNER/OPERATOR <br /> Commissary Name_ CO M M I S SFA#moo <br /> Address_L"__"__ Q S , Samoa S� Bus. Phone20 a • S3 '1 . ZS 7 3 <br /> City (_O J j Zip S7 t/OOwner/Operator Concar <br /> Check all appropriate services provided: <br /> }wastewater disposal ❑ 3-compartment sink Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> TPHot & Cold water for cleaning ❑ Store refrigerated food N tZ notable water <br /> ❑ Store dry food/supplies `Overnight parking _p4ehicle wash <br /> I, Cor cca CLO , 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 shall notify the EHD immediately. <br /> Signature Dateo <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in Californi Health & Safety Code. The above checked services are available at the <br /> above commissary. P se notify EH f e tatus 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 />