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q A NJ�A QUIN Environmental Health Department <br /> COUNTY+— <br /> To,o:% 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 NameC�C�S C\— 4 0-_Lia. Plate# -3 <br /> Owner/Operator Name VcG. t'c:Ivs r, <br /> Business Mailing Address 376 �I t Q `. a24 <br /> CitBus. Ph. t. Ph. <br /> I, , 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 and penalti s. <br /> Signature 2 iy:�a <br /> /� Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name �► ��M P / QCT a �G ,952'0 FA# <br /> Address/,?// —Bus. Phone(2 0 7) 375 { 30' 3 <br /> CityHn das Zip cJ ? Owner/Operator K40 �5 �'e �or�miSSar�i�/nc <br /> Check all appropriate services provided: <br /> CrWastewater disposal El-3-compartment sink Q lectrical hook-ups <br /> G,-Solid waste disposal CF-food preparation O'fioilet and handwashing <br /> Hot & Cold water for cleaning [3,'Store refrigerated food [Potable water <br /> Cn�Store dry food/supplies m,/Overnight parking /ehicle wash <br /> I, Aare Z 5 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 all otify the EHD immediately. <br /> SignatureDate4 lVW22.> <br /> 3. To be completed by the ENV HEALTH 'unsdiction outside of San Joaquin Co. <br /> The commissary is located in S44t aJ 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 if1he status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />