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r 'ry <br />SQN,��AQ��N Environmental Health Department <br />—COUNTY—CCEP, <br />Greatness grows herr-. <br />COMMISSARY AGREEMENT MAR o u 2022 <br />Mobile Food Facility ♦ Caterer ENVIRONINrI.NTAL IILAU'I_H <br />nreaRTMEN'r <br />Complete sections 9 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 ��� '�) O � T— Lic. Plate # <br />Owner/Operator <br />Business Mailing Address \ -6 �-C C K- Jr' <br />City v C 1 State Q�Zip-9 Ld3us. y 1 lt. Ph. 0-':-6 �-- <br />�Al hereby state that the above�'nformation is current, true and correct to <br />the best of my knowledge an agree to utilize my approved commissary, in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Departmenf (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 Densities. <br />-5I'2IzZ <br />12. To be comDleted by COMMISSARY OWNER/O'PERATOR I <br />Commissary Name S & t FA# <br />Address i Bus. Phone ` <br />City 6(Z/ Zip '::?-r i Owner/Operator lD <br />Check all appropriate services provided: <br />p' Wastewater disposal 0 3 -compartment sink Pi' Electrical hook-ups <br />Solid waste disposal 0 Food preparation '0 Toilet and handwashing <br />Hot & Cold water for cleaning O Store refrigerated food 'Potable water <br />0 Store dry food/supplies Overnight parking O Vehicle wash <br />I, , hereby state that the information .l have provided is current, true and <br />correct to he'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 owner shal fy th HD' ediately. <br />1 3. To be comDleted by the ENV HEALTH jurisdiction outside of San Joaquin Co. I <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 <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 />