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,.` SAN JOAQUIN Environmental Health Department <br /> -- COUNTY— <br /> °••,F. ,,,?"' Greotr.,rss grow, hei- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections land 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::�5/4:: P In ri.it Lie. Plate# '77)47z / <br /> Owner/Operator Name`110/ <br /> Business Mailing AddressQ4!,C� /A'elzv <br /> City§Vp44 $[;Zdr State4ZipQr 7ia Bus. Ph.2og^490�//On Alt. Ph. <br /> � � ja� �, 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 A/]fir Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name � \ C.k� �O/ C, o CRc Art FA# <br /> Address 3y f E n-r r rl,� /_ R 9V c= Bus. Phone `tea 0..- IZk�_ <br /> City 9-7-0 CdS�Ten/ Zip op a s' . O nuf e O erator <br /> Check all appropriate services provided: -1 V 0 <br /> 0 Wastewater disposal 0 3-compartment sink CA] Electrical hook-ups 0 Ah3 � <br /> Z <br /> 0 Solid waste disposal 0 Food preparation W; bilet and handwashing m 47 <br /> 0 Hot & Cold water for cleaning ®- Mre refrigerated food E3 Potable water 0 3' C <br /> 0 Store dry food/supplies ELGZernight parking 0 Vehicle wash n M R <br /> I, hereby state that the information I have provided is current,true and to <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility CR C <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the IN M y <br /> commissary owner shall notify the EHD immediately. N Z <br /> Signature X�✓ [[ 'g" _ 'C' , (' Date <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 />