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SAN JOAQUI EnvironmenW f aahrh Depal>"trn n,� <br /> a ,r:atnr-ss yi-ovl5 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 -1, -C.ak Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City o cu-S it State(-�cZip °lS 3 S� Bus. Alt. Ph. <br /> I, '�'\Jmn 9Cmcly (Yes 0, , hereby state that the above information is current,true and correct to <br /> the bet 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 nwalties. <br /> Signature Date -� - Z 3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName S OCK Tota COMMON LTK Kt%e-4Ef 1, FA# \ <br /> Address t l N- EL. DDR&Do 5 o <br /> T Bus. Phone (2 a) (,CS- 5Lk5-Es- <br /> CitZip gSZo 2- Owner/Operator LE0t4EL-- GASTtUL-0 CD-roU tDP-R <br /> Check all appropriate services provided: <br /> Wastewater disposal '&4 3-compartment sink Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> i Hot& Cold water for cleaning Store refrigerated food ( Potable water <br /> Store dry food/supplies 0 Overnight parking Vehicle wash <br /> I, LF-c>KE�- GdS T t� l-o , 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 comp ith the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner al otify the immediately. <br /> Signature Date ��I�9(23 <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 />