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- SAN J O A a U I N Environmental Health Department <br /> -''-I ---COUNTY <br /> Greatness grows her:°. <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 I "1 Lic. Plate# � S ul <br /> Owner/Operator Name S cm n <br /> Business nM'ailing Address _ <br /> City R I�1 StateCLZiplbmBus. PI . `J <br /> � )M 0 53�Alt. Ph. <br /> `` <br /> I n D hereby state that the above information is current,true and correct to <br /> the best of my knowle ge 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 5&7_1-2 -7Date I Z�2� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Namey N ION CST NCo uC, --IA(61 CF, <br /> Address-1117 UNION Bus, Phone(20q ) 2,q 9 5 0 <br /> City��C T� Zip s (Q Owner/Operator N� r 1 <br /> Check all appropriate services provided: W PSS ` ` O N LI <br /> Wastewater disposal 0 3-compartment sink 1 1 Electrical hook-ups <br /> Solid waste disposal 0 Food preparation Toilet and handwashing <br /> Hot&Cold water for cleaning 0 Store refrigerated food Potable water <br /> Store dry food/supplies 0 Overnight parking Vehicle wash <br /> I, SUS E[ SEN 1"I O LbO , 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 owners II notify EHD immediately. <br /> Signature Date ,/�/7 <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 /> PV- 05 '-� kD'e) bC'I <br />