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r SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> Greotness gro;;s ;sere. <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 Name 1) •M/a W /6C Cgf-f)M Lic. Plate# <br /> Owner/Operator Name_r ZVttAkOz ,k WfO ( i u,:4 <br /> Business Mailing Address 9 o U c� C S �J(if <br /> CitStater$Zip Gl f tl !: Bus. Ph. Cftfk,nLiaAlt. Ph. <br /> I, P 'QVI(4Q rk A1.1 _"eby state that the above information/ is current,true and correct to <br /> the b st 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 penalties. <br /> Signature y�u9L!M Date <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name {� I K n1 GO FA# <br /> Address 3(l! L^ V6 Bus. Phone <br /> City SF'a C&7-6/1/' Zip c'} 015'aoS Owner p rator <br /> Check all appropriate services provided: n 7C <br /> p Wastewater disposal [3 3-compartment sink M Electrical hook-ups m Z <br /> p Solid waste disposal 0 Food preparation Toilet and handwashingZ 3 0 <br /> • Hot& Cold water for cleaning \� Store refrigerated food [3 Potable water n Z n <br /> • Store dry food/supplies Overnight parking [3 Vehicle wash > X <br /> I, hergby state that the information I have provided is current, true and CCA D <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility N 111 M <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the N <br /> commissary owner shall notify the EHD immediately. 3 <br /> Signature ��?N� �' t 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />