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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 <br />Business Name gainhow Lic. Plate # N L c, => I <br />Owner/Operator Name hTn c4J <br />Business Mailing Address u r-1 � b r <br />City M . ^t ecc. State CA- Zip S 3"31+ Bus. Ph. 209 t4B 3 �6- Kl Alt. Ph. <br />I, MJ SSn;L. , 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 E Failure to notify this office may result in permit <br />revocation and penalties. _ M. <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />A <br />Commissary Name Er_�c (: U FA# <br />Address 3141? & f1Yt'P'- c7nia Bus. Phone <br />City S Iy, K Imo- Zip ICC Lv S` Owner/Operator cyt i.. <br />Check all appropriate services provided: <br />❑ Wastewater disposal ❑ 3 -compartment sink electrical hook-ups <br />❑ Solid waste disposal ❑ Food preparation t3; Toilet and handwashing <br />❑ Hot & Cold water for cleaning MStore refrigerated food ❑ Potable water <br />❑ Store dry food/supplies 11210vemight parking ❑ Vehicle wash <br />"o <br />x <br />Z <br />O <br />O <br />I, , hereby state that the information I have provided is current, true ang <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facilitxo <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, thT <br />commissary owners all notify the EHD immediately. p <br />����I <br />Sicnature 1✓L Cw.. Date %—/y-23 cn <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 Signatu <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 />M <br />X <br />a <br />