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SAN JOAQUIN Environmental Health Department <br /> COUNTY <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 / /1 <br /> jOwneBusiness Name // � ,C Lic. Plate# `t T6 93 75- <br /> Owner/Operator <br /> r/Operator Name <br /> Business Mailing Address 1Vs,� Li-idUPD <br /> City nnState Zip9s3310 Bus. Ph��Q�� Cp -53f.3Alt. Ph. <br /> /� <br /> I, 'ga"r) h'' UI/to hereby state that the above information is current,true and correct to <br /> the best of m nowledge 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 Date .3hilZO <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name GRTCPAICT 7&K �tl`JM — Ig <br /> Address /7 17 ,5, a4110,11-5-r. Bus. Phone Ig JD <br /> CitysTbCkT01V, CR Zip Owner/Operator <br /> Check all appropriate services provided: <br /> Q"Wastewater disposal M'3-compartment sink electrical hook-ups <br /> M-Solid waste disposal M4Food preparation CV/Toilet and handwashing <br /> -lot&Cold water for cleaning [96tore refrigerated food ��otable water <br /> DIStore dry food/supplies w6vernight parking t1 Vehicle wash <br /> I, /�� J /R'J 4 d , 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 II no fy th HD immediately. 2 ` <br /> Signature ,LTJ Date✓ 7i� ZO Z 3 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of 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 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />