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SKJOAQUIN a <br /> ,2 . Environmental Health Department <br /> " I�eu� —COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections t and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed b APPLICANT <br /> n <br /> Business Name /,� S L / S OL J` <br /> {{ Lic. Plate# <br /> Owner/Operator Name 7 y Cf� <br /> Business Mailing Address / 13 '© .J e Wb() G <br /> city GSGAGO"Ji state ChZip qSg z17 Bus. Ph 0 29 -6i /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 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 pena ies. �� <br /> Signature /'�/��V Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Nameb FA# Z2 " n� n-1 T(p <br /> Address �os—lT�PM� �t �{�e Bus. Phone 209 �C'3' 41(D <br /> city ��Cc�r�r� Zip QOwner/Operator <br /> Check all appropriate services provided: <br /> ,a Wastewater disposal AJ 3-compartment sink 41 Electrical hook-ups <br /> Solid waste disposal $ Food preparation )a Toilet and handwashing <br /> , Hot& Cold water for cleaning I Store refrigerated food O_Potable water <br /> ,M-Store dry food/supplies JT Overnight parking Er Vehicle wash <br /> S1,17-Th hereby state that the information I have provided is current,true and <br /> correct to the est of knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator tails 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 / �QM9zjq Date 7 <br /> 3. To be completed by the ENV 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.sjgov.org/ehd <br />