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SAN:,JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> ?e- Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility t 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 com feted b APPLICANT <br /> Business Name TIA Lic.Plate# <br /> Owner/Operator Namecfwwo <br /> Business Mailing Address )2-4 E t�:t11(,t�–� <br /> City_ �i1 StateZip a5 Bus. Ph.a Sb5•'��JAIt. 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, and2s. <br /> Joaquin County En ' onmental Health Department (EHD) requirements, If the use of the <br /> commissary is d' ue , h er hol a must notify the EHD. Failure to notify this office may result in permit <br /> revocation an ea <br /> Signature t141 kl J Date—\\ ZZ <br /> 2, To be completed bySOMMISSARY OWNER/OPERAT.OR <br /> Commissar Nam GL FA# // / <br /> Address aS we ,,00y�� aj&5" Bus. Phoncp, o 9f– `Y' T S 9� _ <br /> City th 1!4 Zip 5,30 Owner/Operator w) G/ i <br /> Check all appropriate services provided: <br /> D§ Wastewater disposal d 3-compartment sink td Electrical hook-ups <br /> 19 Solid waste disposal p Food preparation of Toilet and handwashing <br /> 0 Hot& Cold water for cleaning ❑ Store refrigerated food 11 Potable water <br /> E3 or dry fgod/sugMes at Overnight parking &Vehicle wash <br /> I, OVIY-E � A'– , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowle�' Wndition <br /> nd meets the Califo is Health&Safety Code requirements. If the food facility <br /> operator fails to comply with ths of this agree t, or if this agreement is modified or cancelled, the <br /> commissary er shall noti EHD immediately. <br /> Signature ----_ Date -a-- <br /> F3. To be completed by the ENV HEALTH jurisdictipa-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 />