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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> 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 Name PrtZ: "e, Lic. Plate# <br /> Owner/Operator Name E7 i _a �o„�� <br /> Business Mailing Address fj I I Inta:,✓t S�- <br /> City State,_6_)�CZip `/S Bus. Ph.jjM590—';(`f03 Alt. Ph.(�uu�O_Sb— F63 <br /> I,_6(t2cL-vc.A;o. , hereby state that the above information is current, true and correct to <br /> the best of my kno ledge 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 a d penalties. <br /> Signatur —� Date 05/0 ' ( 7_0Z3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address (oZ6 � f- , Bus. Phone 26 22 9— F3 31Y <br /> City fib; Zip �� ���� Owner/Operator L�64'_ rr' <br /> a <br /> Che all appropriate services provided:: <br /> Wastewater disposal H'3-compartment sink `' ectrical hook-ups <br /> " lid waste disposal Food preparation T�o'ilet and handwashing <br /> h'Z"tore <br /> & Cold water for cleaning St re refrigerated food hl�Potable water <br /> dry food/supplies Overnight parking li,)lVehicle wash <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 <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owney shall notify the EHD immediately. <br /> Signatures Date o'?_3 <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 />