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T <br /> :UF U'yry � <br /> SANJQAQUIN Environmental Health Department <br /> I.^ —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 completed by APPLICANT <br /> 9 <br /> Business Name i r S Lic. Plate# 8U C Igo 3 <br /> Owner/Operator Name gNVg l o_V--t 1 <br /> Business Mailing Address r _-"cr' IT <br /> - <br /> City, <br /> $ <br /> City ��State�ip 75166 Bus. Ph. 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 penalties. <br /> Signature SOV)[ Ane- 2ln&0r' k fVe_C-'-' Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name (;t/IPur nrc_ r.tc �jWPk2 FA# <br /> Address Z V V() 4. AN{��r�— Bus. Phone '2.y� - S6 ) - /y6 A <br /> City_54:E2cj0" Zip CI 5&uf6 Owner/Operator �_u aL <br /> Check all appropriate services provided: <br /> R Wastewater disposal 3-compartment sink 1W Electrical hook-ups <br /> jg Solid waste disposal P,l Food preparation 1Lt Toilet and handwashing <br /> 9 Hot& Cold water for cleaning dJ Store refrigerated food & Potable water <br /> M Store dry food/supplies 0 Overnight parking Or Vehicle wash <br /> I,�g4ne:& y , 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 Date_ to <br /> r <br /> 3. To be completed 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 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 />