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SAN JOAQUIN Environmental Health Department <br />—COUNTY– <br />a'': 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 />1. To be completed by APPLICANT <br />Business Name TGL( _� / L,_ Lic.Plate# �lSFID�� <br />Owner/Operator <br />Business Mailing Address oAJ2S / t Y/JIDCYy' 6'-c <br />City StateM Zip !J! i '6 Bus. P4Ae/-9;l3-el3J Alt. Ph.gef- Y75 ogddD <br />I, AauiRxe , 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 />revocation �anI dOein/aMltes. <br />Date 0 1— ['-'!T- --Z 1 <br />12. To.be,comoleted by COMMISSARY OWNER/OPERATOR <br />Commissary Namq <br />Adrlracc A %,12,�9 <br />Check all appropriate services provided: <br />Wastewater disposal 3 -compartment sink ® Electrical hook-ups <br />Solid waste disposal [3 Food preparation 0 Toilet and handwashing <br />E2 Hot & Cold water for cleaning O Store refrigerated food M Potable water <br />Ore dry fLood/supplies 110 Overnight parking E3 Vehicle wash <br />I,nN/4 h- Z 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 th nditions of this agreement, or if this agreement is modified or cancelled, the <br />commissaryv er shall not a EHD immediately. <br />Signature. <br />3. To be completed by the ENV HEALTH iurisdiction 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 <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 />