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SAN l0AQU1N Environmental Health Department <br />---COUNTY--- <br />_ <br />COMMISSARY AGREEMENT <br />Mobile Food Facility a 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 APPLICANT <br />Business Name Lic. Plate # S <br />Owner/Operator Name G202aQ. Iv2Z <br />Business Mailing <br />Ph.ZOC( Z,�Z9q(/S-Alt. <br />hereby state that the above information is current, true and correct to <br />the best of y knowledge a d 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 />Commissary Name I KL U i fn U i 07 e c FA# <br />Address d� Cad. Torn.,"j jt Bus. Phone CZo`� l �'�'706- <br />City lizip 1 120 Owner/Operator f �-ii t\Z✓ r�l J1 t 11 r) <br />Check all appropriate services provided: <br />[� Wastewater disposal Q 3 -compartment sink 0 Electrical hook-ups <br />p Solid waste disposal El Food preparation Ek Toilet and handwashing <br />lL Hot & Cold water for cleaning q Store refrigerated food ❑ Potable water <br />'9 Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br />L gni 4Qsj 1�1o1 1yLC , hereby state that the information I have provided is current, true and <br />correct tot 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 ower s_41I notify the EHD immediately. <br />Signature <br />3. To be com itted 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 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 <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 />