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T SAN :_JOQQUIN` Environmental Health Department <br /> —COUNTY— <br /> Greocrass grow: 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 Tobe+corn5Ietectrb. ARP;LfCAIVT�;I , .,,r ,.� <br /> Business Name�rz- P_ 1-P &&,,_!, Lic. Plate# '77/47/.I,/ <br /> Owner/Operator Name r0/nl N,044 zew <br /> Business Mailing,Addressgl , &, azq <br /> City�C "4 Stateg�z Zip Bus. Alt. Ph. <br /> I, 1L4 4j4&e e _� �, 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 /> D <br /> Signature 4C, &/ C, Date I)kj�/�,��� <br /> 2. Tci:be.cor ' IetedL-b .,CQMMISSARY�TOUIfNER/OPERAT.,OR ,4 <br /> Commissary Name V \ C.�/, t7 o 9CC (f PG_ Ae1 _FA# <br /> Address 3r4fA C-- o-7 r e✓ Fa R P_V_e= Bus. Phone cL- C k - '--I'Z\.g <br /> City STG CSC7_dn/ Zip C?q- as�,5--Owne O/r Aerator co 2 <br /> Check all appropriate services provided: w C1 <br /> ❑ Wastewater disposal 0 3-compartment sink 1p Efectrical hook-ups n N � <br /> TmZ <br /> ❑ Solid waste disposal ❑ Food preparation &i,-Toilet and handwashing 4 . Im <br /> ❑ Hot & Cold water for cleaning O3tbre refrigerated food ❑ Potable water Z 3 Q <br /> ❑ Store dry food/supplies [t1-AMernight parking E3 Vehicle wash D M R <br /> I hereby state that the information I have provided is current,true and W D <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility (A < <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the p M rT <br /> commissary owner shall notify the EHD immediately. <br /> Signature--Z— <br /> ..Date <br /> 3. To`.:be com feted b'. tFie ENV HEAL°TH, uRsdictian+o'uts'ideSofSanJoa"uEn�Ca F <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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />