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SAN�JOAQUIN p <br /> / °� Environmental Health Department <br /> `j —CCUNTY— <br /> `-4r,FOQap' 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 /> I. To be com liptqd'by APPLICANT —1 2 <br /> Business Name1r �� 1, Lic. Plate#45F r I ? S <br /> Owner/Operator Name Fi71VI6U) iIOIA4 COOT naS <br /> Business Mailing Address i70 61))( c3s I I <br /> city 5WV-j State `(/�1_- Zip q 5 e)Bus. Ph.L01 ( 3I i Alt. Ph. 211`1 ' <br /> I,FV9I►1C ISC1D 1(q fA0S C0 0 hfc' )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/p (ties j <br /> Signature ii Date <br /> 2: To be completed leted b COMMISSARY OWNER/OPERATOR <br /> Commissary Name G I C� l' (4 I III hD INC, FA# <br /> Address I00 LN) . L-t,v15dff,Ak) Bus. Phone 21 0 to�5 I _ 3 1 qr <br /> �t V <br /> City S j Zip ��� Owner/Operator�ilfl(45CC) 11AA I45 6L 1'fY'tr'MS <br /> Check all appropriate services provided: <br /> S(Wastewater disposal E1 3-compartment sink Ci Electrical hook-ups <br /> Of Solid waste disposal Food preparation 9 Toilet and handwashing <br /> 14 Hot& Cold water for cleaning D Store refrigerated food Or Potable water <br /> [!(Store dry food/supplies Cr Overnight parking GKVehicle wash <br /> 1,TWm1CI SCb 11(41MA3 I„f]W3 , 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 o r sh notify EHD immediately. r� <br /> Signature Date la 1-2 <br /> .. _ .•._ _.. .._. . . � �CMN. _.M1 _ ..� y, <br /> 3. To be com» leted b the ENV HEALTH •unsdlcttori outside of SI 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br /> 0 <br />