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�,f <br /> SAN ,OA U I N Environmental Health Department <br /> ' 1 <br /> C 0 U NTY <br /> °17p Greatness grows her?. <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 cpmplleette`d by APPLICANT <br /> Business Name ` 0CL4D _ ;�_Lic. Plate# <br /> Owner/Operator Name VF 7cc rs t C' 1�L2EF� 1V 2 -C�- <br /> Business Mailing Address 7L s Q Fav 26 <br /> City A {,� .y s,v,, State�i 2/S- Bus. Ph. ( 5/n� 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. ,� f <br /> Signature /L/' Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> l <br /> Commissary Name Ch �e2 M r /S ct CC e /"/Cgr- X9-5 FA# <br /> Address/,,"2// g � � . �j?'� ��r--� Bus. Phone(2 0!7)37_ 2•- 3�6 <br /> City <br /> �- Zip J" / Owner/Operator �o/d S j e �or�rni S�tr y� enc <br /> -- <br /> a-- <br /> Check all appropriate services provided: <br /> VyWastewater disposal [1-3-compartment sink 13-161ectrical hook-ups <br /> p"Solid waste disposal mood preparation 13," oilet and handwashing <br /> 0"Hot & Cold water for cleaning O/Store refrigerated food Potable water <br /> EVStore dry food/supplies ®Overnight parking Ea ehicle wash <br /> I, .14 r4 Lai- ' G'Ve , 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. J <br /> Signature - Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in 1 t RU , 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 t status of their operating permit changes. <br /> REHS Signature_ �� �% ItiY Date b �Z () Z <br /> g � <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 />