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Environmental Health Department <br /> SAN. JOAQUIN p <br /> —COUNTY— <br /> °; Greotness grows here. <br /> .oma <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 /> Business Name 0 I ce-22 Lic. Plate# <br /> Owner/Operator Name ap �a l r��2o/" <br /> Business Mailing � <br /> Address 1 l' — <br /> CityU CLM Statt a� 9X)9Zip 9J Bus. Ph. q W0l ' q It. Ph. <br /> 1 ��(( ���(l. , 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 discontinued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocationa penalties. 1k <br /> Signature Wv � Date � — �O � �/ ZZ <br /> 2 To be completed b COMMISSARY 01NNER/OPI=RATORt , <br /> ^� Commissary Name ; 41;, FA# <br /> Address S a2c t I CJ 17y Bus. Phone G <br /> City ��( Zip C(Z Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal Gr3-compartment sink ❑ Electrical hook-ups <br /> Solid waste disposal �q Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning EKStore refrigerated food Potable water <br /> Store dry food/ upplies ❑ Overnight parking ❑ Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> corredl 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 of the E immedi ely. <br /> Signature / Date40�Z-- <br /> t .FvAv ' r i S 4A1t r v—erry$x <br /> 3. To corn .letedb ,the;ENU=HEALTH: urisd(ctlo o?t�ts�de of, S;an Joan <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 /> Labove commissary. Please notify EHD if the status of their operating permit changes. <br /> lea' <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 www.sjgov.org/ehd <br />