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f- 2'j-s 0 I S R vnj?6 q 2 <br /> SAN:OAQ U I N Environmental Health Department <br /> COUNTY <br /> Greotness grows here. <br /> gi"caac'- 7 <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 I(\/D r k, ': 1�AQCQ ,,I iy I Lic. Plate# U <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City Stat ,A Zip . Bus. Ph. 0�1--32�`�'7��It..Ph. <br /> I, CCT, H , 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 Wj Date C) <br /> 2. To be completed by COMMISSARY OWN/ER/OPERATOR <br /> Commissary Name -� 'S � �L <� FA# <br /> Address SucI,/Z ; Bus. Phone <br /> CitZip Owner/Operator // / <br /> Check all appropriate services provided: <br /> �[ Wastewater disposal O 3-compartment sink ® Electrical hook-ups <br /> Solid waste disposal O Food preparation W Toilet and handwashing <br /> ER Hot& Cold water for cleaning [3 Store refrigerated food tr Potable water <br /> 0 Store dry food/supp)ies El Overnight parking Et vehicle wash <br /> I, -e A � Lam. , hereby state that the information I have provided is current,true and <br /> correct to the best of my know!Age,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 owners II notify the E ediately. <br /> Signature Date V } <br /> 3. To be completed by the 8NV HEALTH jurisdiction outside of San Joa uin 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 I T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> S <br />