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S A N J O A Q U I N Environmental Health Department <br /> --COU NTY-- <br /> Greotness <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility A 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 Name4a � 3 CTHs <br /> Owner/Operator Name k I CPr_vC 4-1t, 9 Di 0 }I&CA4044-2 <br /> Business Mailing Address 3 F-YZo C AMA Ay fes' <br /> City 10 AJL State_4zip 9_L�us. Ph. (2,00) SIL - V Alt. Ph. <br /> I, kC I( Pi)o h/&eiLJJA 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 pe14 rmit holder ust notify the EHD. Failure to notify this office may result in permit <br /> revocation penaltie r Z <br /> Signature Date / 2 I�`J <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name (J k) 10A� C PET(--i 1c 14J(-,l 1!QU_js CLL_ ctA# <br /> Address �]f 7 5• U Ai ilk AJ S7 Bus. Phone C20C13 2C07— ,5 -/Z(,, <br /> City �)RCK7UA_Zip Owner/Operator a� <br /> Check all appropriate services provided: N 0 S70 CAG F <br /> ® Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ® Solid waste disposal ❑ Food preparation (21 Toilet and handwashing <br /> P Hot & Cold water for cleaning ❑ Store refrigerated food P Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking [8 Vehicle wash <br /> I, 'A C 1 7/Z2n , 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 ow er II n fy the EHD immediately. <br /> Signature Date " <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 />