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SAN 1OAQU N Environmental Health Department <br /> u' <br /> ---COUNTY— <br /> Greatness <br /> _..__COUNTY---- <br /> Greatness rgrowS 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 b APPLICANT <br /> Business Name S11 j1 Lic. Plate# V <br /> Owner/Operator Name m �AIh-l) y <br /> Business Mailing Address �� 2 G , T <br /> City, State Zip a Bus. Ph. Alt. 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, 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 /> Signatur4 f 1,1 Z4, Date <br /> 2.. To be completed by COMMISSARY OWNER/OPERATOR, <br /> Commissary Name �' i CK nl eio -4C5,_ CRE �,m FA# <br /> Address 3 y I E, m �'o�/� q fA Y6 Bus. Phone n V\4'- !y7 Lf <br /> CityS�o c K--o n/ Zips Seo_�' Owner O/perator <br /> Cn <br /> Check all appropriate services provided: 0O ;b. 7g <br /> Wastewater disposal 3-compartment sink Electrical hook-ups C7 N <br /> Solid waste disposal [3 Food preparation Toilet and handwashing m C' <br /> F. O <br /> " Hot & Cold water for cleaning Store refrigerated food 0 Potable water Z Z n <br /> Store dry food/supplies Overnight parking Vehicle wash D X n <br /> I, hereby state that the information I have provided is current, true and D ,'p <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility N m m <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the 3 <br /> commissary owner shall notify the EHD immediately. <br /> Signature SX.— Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outsideof 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br /> �,� 0 5 .2 ip 09LI <br />