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SAN 1QAQUIN Environmental Health Department <br />— COUNTY— <br />Greatness grows 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 corn leted by APPLICANT <br />Business Name -;5 14 o 1„ h rz,� F� Lic. Plate # <br />Owner/Operator <br />Business Mailing <br />CitV0K Gro k <br />I, 59r -0\r! O A A):aq 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 lend penaalt'S. <br />I1 n l ,✓ — 1 Ilatw (S 311 '— Z-0 ZZ <br />9_ Tn tie comDleted by COMMISSARY OWNER/OPERATOR I <br />Commissary Name jf'&t rf ' f- F"ff <br />Address,�I/L ��,t,,` Bus. Phone q�/ 1C/V �% <br />Z <br />City Ldp✓ zip--JOwner/Operator 1� r <br />Check all appropriate services provided: <br />a Wastewater disposal EI 3 -compartment sink 1019 Electrical hook-ups <br />t Solid waste disposal i7 Food preparation Ft Toilet and handwashing <br />R Hot & Cold water for cleaning Et Store refrigerated food 'Q Potable water <br />O Store dry food/supplies Niles Overnight parking q Vehicle wash <br />I, A/o l'06144JY --r hereby state that the information I have provided is current, true and <br />correct to the best of my ky wledge, 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 nytify the)iHD igrnp <br />tely. <br />3. To be completed by the ERIK/ ' EALTH jurisdiction 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 209 464-0138 1 www.sjgov.org/ehd <br />POro 61�gA <br />