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��o�►z� �� � P�2 �sy�l3�l <br /> S A N J QQ Q U I N Environmental Health Department <br /> COUNT Y <br /> �q _} 1' Greatness groves here. <br /> Oliver Disu tmmo►. <br /> COMMISSARY AGREEMENT ' Co � <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 Ci GCS 1 _sCi o 6 Lic. Plate# <br /> Owner/Operator Name Kc)6,4y+v 0� w(ar'l4 ` �D�'► <br /> Business Mailing Address '3/ Z 'u1 � <br /> V iy1 Ce <br /> City dStateM Zip CI I Bus. Ph. Alt. Ph. <br /> I, D L C--0411 , 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 p rmit holder must notify the EHD. Failure to notify this office may result in permit <br /> ,revocation and penalties ���`� <br /> Signature ° Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> 11"' 1- <br /> LL( <br /> Name t�I I U �'S �I i�jr+�t71,t ,ovi � �is # <br /> Address ��� - � r o� Bus. Phone <br /> City Til V I _0 Zip 96 O Owner/Operator-Tk/n%c &e/ Ct_in <br /> Check all appropriate services provided: <br /> Q'Wastewater disposal 0'3-compartment sink O'Electrical hook-ups <br /> Solid waste disposal EI'Food preparation HI Toilet and handwashing <br /> Id Hot & Cold water for cleaning Ef Store refrigerated food EfPotable water <br /> E{1 Store dry food/suppli s P."Overnight parking G1 Vehicle wash <br /> yReA , 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 nWOie EHD immediately. <br /> Signature Date 2-i> Z3 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> 'The commissary is located in S+e(r1is latus C<xt y. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. Treat7e checked services are available at the <br /> above commissary. Please notify EHDifthe status of their operating permit changes. <br /> REHS Signature l) Date ��("LF2 <br /> 1868 E. Hazelton Avenue I Stockton, Cali ornia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> s <br />