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SAN 10AQUIN <br /> 1- Environmental Health Department <br /> tLti � COUNTY <br /> Greotness 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 Name e,-) )4 N D H 1 E C P 15 m Lic. Plate# $ "F"` S -N -3 ° S <br /> Owner/Operator NamS j N 6 t- S A N 0 F) \j <br /> Business Mailing Address '� 6 3 a p Al &/=- L 1 N 10 L N <br /> City s 1-0 C-u Tin NStateCA-Zip I S l.2 Bus. Ph. ;� G G. ti 3' b6glt. Ph.22° 4 u`S 3 — 9 6 6 <br /> I, M U K r-►1 A R - 3 - S y1 1Li 4« y 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 penalties. <br /> Signature dot tj.-, Qt;:' iS�e.�.-r 1� �I,4 A+—� Date SJ- o"? D Z 3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name P I CK c?/ o 4�Q c-'zcc," _FA# <br /> Address 3 �j l �, L rn�'�l L f� R V E Bus. Phone a- °I - <br /> City S CGC To+,/ Zip ell Cf s2o S Ow r/Operator CA ` <br /> Check all appropriate services provided: <br /> O <br /> D Wastewater disposal D � <br /> 3-compartment sink iectrical hook-ups m <br /> i et and handwashin <br /> D Solid waste disposal D Food preparation 9 O 3 <br /> D Hot & Cold water for cleaning Q Store refrigerated food D Potable water 'Z <br /> D Store dry food/supplies 910vernight parking D Vehicle wash D ; <br /> fn <br /> 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 C rn <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 EHD immediately. <br /> Signature S � Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />