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4' <br /> oFouiN cl <br /> < � Ga,, SAN ,]DAQUIN Environmental Health Department <br /> COUNTY— <br /> ter �c:lr Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility �p Caterer <br /> Complete sections 9 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 % G�� cv)o r 2 ' C Lic. Plate# LI S 2 6 3 <br /> Owner/Operator Name �� Jc'Gt �Q <br /> Business Mailing Address 949&-- 5 Coe 4, <br /> City �� OC,lL�4/oStateeWZip 2522j Bus. Ph. Alt. Ph. <br /> 1, Z _cfyG f—,G/(WW-, 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 an alties. G/ ` <br /> Signature _ � �/�G/!`l�Q� Date S/ ,moi 20 2-3 <br /> 2. To be completed by COMMISSARY O /WNER/OPERATOR <br /> Commissary Name L g/� FA# <br /> Address / /�� Bus. Phone !� 3 <br /> City Gi�/} Zip `—Owner/Operator <br /> Check all appropriate services provided: <br /> Ig Wastewater disposal ❑ 3-compartment sink Int Electrical hook-ups <br /> IX Solid waste disposal ❑ Food preparation Of Toilet and handwashing <br /> PHot & Cold water for cleaning 15r Store refrigerated food ❑ Potable water <br /> ❑ Store Z) . <br /> food/supplies Overnight parking la"Vehicle wash <br /> I, x - A , 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 notify the F <br /> 040 immediately. 1-7 <br /> Signature Date SS— �—O <br /> 3. To be completed by t66 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 />