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S A N iJ OA Q U I N Environmental Health Department COUNTY r' Greatness grows here COMMISSARY AGREEMENT Mobile Food Facility Caterer Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. 1 . To be completed by APPLICANT Business Name G�� p At r4 J RI.P re Lic. Plate# 7 Z Owner/Operator Name � 1. J'AJ Crx4} Business Mailing Address 0 9;;, 7cD City� 410- cwl State( Zip 2 Bus. Ph. — Z — _61i h. I, hereby state that the above information . current,true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit revocation an enalti Signature Kr1 Date 2- 2. 2. To be completed by COMMISSARY OWNER/OPERATOR Commissary Name_�,, FA# 00,2 T Address_ / (P .2 0 l � 11gr A nj _ Bus. Phone Og - 71 Z— 15 t& M city c.,p Zip Owner/Operator &.2V.e_ Roewls--IF-44 Check all appropriate services provided: / VWastewater disposal 133-compartment sink M Electrical hook-ups Solid waste disposal ❑ Food preparation IdToilet and handwashing ❑ Hot & Cold water for cleaning ❑ Store refrigerated food VPotable water ❑ Store dry food/supplies Overnight parking EJ Vehicle wash I, f1[Jc' !In C-4 hereby state that the information I have provided is current, true and correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the commissary own hall no e EHD immediately. Signature Date 7/x 2- 3. To b com leted by the ENV HEALTH jurisdiction outside of San Joaquin Co. The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd gM t ) tq d L3€ET KHAT ��3 �i�`-i�9 c. - Co"