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r <br /> SAN. JOAQUIN <br /> Environmental Health Department <br /> r� r <br /> ----COUNTY— <br /> Greatness grows here. <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 Pl 7 9Gfnl,�34' to Lic.Plate# <br /> Owner/Operator Name C'-'P46t y (� tno ) .e-a t <br /> Business Mailing Address rt4 R� <br /> City S State—Zip S�)'d(Bus. Ph. 209 2375��Ft. Ph. <br /> I, t!', �Eara2ehereby 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. 4 <br /> Signature �y�4 tC✓ mac/(/1_� 22= B, Date <br /> `2. To be completed by <br /> ,C`O/MMISSARY OWNER/OPERATOR <br /> CommissaryName��:rk Iy leo FA# <br /> Address '012- E Aiuf am Bus. Phone SDC( <br /> Citygjb,g� Zip gSZof Owner/Operator <br /> Check all appropriate services provided: <br /> E3 Wastewater disposal O 3-compartment sink 1WElectrical hook-ups —4 fe 0 <br /> O = X <br /> p Solid waste disposal O Food preparation 8"Toilet and handwashingO N Z <br /> m <br /> O Hot & Cold water for cleaning SStore refrigerated food O Potable water O 3 O <br /> O Store dry food/supplies $Overnight parking [3 Vehicle wash Z Z n <br /> I. Ca 4A ffL QS«L erne" hereby state that the information I have provided is current,true m m <br /> correct to the beslTof my knowledge,and meets the California Health&Safety Code requirements. If the food fa� n <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled,&e � <br /> commissary owner hall notify the EHD immediately. // m 3 <br /> Signature7� 1�/! Date // ( Z �j ic <br /> 3. To be completed by the ENV 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />