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SAN_ OAQUIN Environmental Health Department <br />—COUNTY— <br />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 />Business Name I,–& IT ti-c-I–/'r" Lic.Plate# <br />Owner/Operator Name rMp I y__ A'V-vC— L <br />Business Mailing Address �I� ✓ (Y� SI ' <br />City, ��'" State C -Zip < 2- Bus. Ph.7\i —Alt.Ph. <br />I, � . S �(^c.� e' 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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Nilo 11c FA# <br />Address 4 AMY, A Bus. Phone <br />City ( tai Zi02.5Zj!(— Owner/Operator <br />Check all appropriate services provided: ,� r� <br />Wastewater disposal 3 -compartment sink ,qv Electrical hook-ups <br />Solid waste disposal Food preparation (� Toilet and handwashing <br />Hot & Cold water for cleaning Store refrigerated food Potable water <br />Store dry food/supplies wOvernight parking � Vehicle wash <br />I, CC 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,owner shall notifrg the EHD immediately. , <br />0LiG(er'z <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 />a <br />