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,-oF,duini c_ <br /> 2 r , SAN JOA0UIN Environmental Health Department <br /> —COUNTY— <br /> F_1 Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility♦ Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT 3 Trr u�[ <br /> Business Name Lic. Plate# 7 hq v°(Zn q9 <br /> Owner/Operator Name J 1 r? R r (, GiH G rn fin/ SW <br /> Business Mailing Address S e l o 2- t Ir (o <br /> City S'fo G9f'Irr'/C/ State c LZip 4c�Bus. Ph. °fin 0-4,43 -21,I0 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 penal ies. <br /> r <br /> Signature Pl an i t�Y 4 GAQt1 Date j 020 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name %N Yto 97 S S 9 V1 1 FA# <br /> Address 3_$7 MIM FV E i-7 l,� 0 ,1 Bus. Phone Q�,V%r– 1'7 W G <br /> city S (mea/ Zip COL Owner/Operator <br /> Check all appropriate services provided: <br /> E3 Wastewater disposal C3 3-compartment sink ioElectrical hook-ups N T <br /> W <br /> p Solid waste disposal O Food preparation orlet and handwashing 0 � x <br /> M Hot & Cold water for cleaning I3-15tore refrigerated food El Potable water 0 m Z <br /> Cl Stored food/supplies lies - C) <br /> dry pp QV6vernight parking O Vehicle wash <br /> I, O <br /> hereby state that the information I have provided is current, true and ? Z <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility n m n <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the > X <br /> commissary owner shall notify the EHD immediately. W D 0 <br /> cn < m <br /> Signature _ Irr a.„ ,f, �cw:q' Date_ / /^ q —`cl p M D <br /> 3. To be com le�edb 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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> ?l454VI'I 1 P�o55lot60 t I?K,()5VN S <br />