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SAK JOAQUIN Environmental Health Department <br /> —COUNTY— -- <br /> c�cP' Greotness grows hr . <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 _n'S GWW DO GS Lic.Plate# y0 (A 45 <br /> Owner/operator Name ,Twe RGUllprw <br /> Business Mailing Address %07- S. CenTrc,l .Avp, <br /> City L.od i State Ch Zip `15240 Bus. Ph. 201 Alt. Ph.jQ°I° L1Kl83 <br /> I, U W, Ar7 U l 1'e r°" 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 Cade, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is 'scontinued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p nalties. l`I Signature Date <br /> 2. To b leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ��Wl/?�,�l / PZI-r, FA# <br /> Address 1x20 Sacyv,. +j, Bus. Phone 7'el $s39 <br /> City J-!JD Zip -152 YL Owner/operator Akjw✓w 6Z+- <br /> Check all appropriate services provided: M/ <br /> (rIVastewater disposal 9/3-compartment sink DYElectrical hook-ups <br /> //Solid waste disposal Food preparation UP/Toilet and handwashing <br /> M Hot& Cold water for cleaning MStore refrigerated food La Notable water <br /> Store dry food/supplies 19/Overnight parking 11211'�Vehicle wash <br /> I, )k74'ec,&_ , 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 44g*I2✓ Gp` 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 />