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SAN JOAQUIN Environmental Health Department <br /> - --COU NTY— <br /> Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 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 l Lic.Plate -5-53 <br /> Owner/Operator Name fT°A 1.u t Z �r� <br /> Business Mailing Address �k _ P-3 d apta 1P - <br /> City 1-'1xn fro State quip 9 5 iT9 Bus. Ph. 10 L,`lo-b teiAlt. 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 penalties. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryNameG.A-1 <br /> I s SFA# <br /> Address 2 /+ <br /> yo S• lrPpr Bus. Phone) �2 o) j — 5761- 1V6- <br /> City GrIA,64 7ip--95704 Owner/OperatoreracS <br /> Check all appropriate services provided:: —/ <br /> I'1/Wastewater disposal M/3 compartment sink W"EElectrical hook-ups <br /> Q/Hoolid waste disposal ;Food preparation a Toilet and handwashing <br /> t&Coldwater for cleaning Ey Store refrigerated food /Potable water <br /> IYStore dry food/supplies Overnight parking M Vehicle wash <br /> 9-66010 0 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 =!,���T Date <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 />