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SAN 10AQUIN Environmental Health Department <br /> COUNTY <br /> RECHVE <br /> COMMISSARY AGREEMENT <br /> JUL 2 0 RFI''.') Mobile Food Facility * Caterer <br /> SANTA CLARA COUNTY <br /> DEPT OF ENVIRONW-NIT L HEA "( <br /> C #er+s i-�po't _. f your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be completed b1 APPLICANT <br /> Business Name i 1�\Q �q I Lic. Plate# "1 <br /> Owner/Operator Name n i <br /> Business Mailing Address Gloa6cwc `C, y <br /> City State Zip Bus. Ph. 4(,)i6 ?�7-7C 05 Alt. Pd L46 ' 39 3 <br /> I, 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 J ty E viron ent Health Department (EHD) requirements. If the use of the <br /> commissary is dis tinued, the p mit ho er t t�fy the EHD. Failure to notify this office may result in permit <br /> revocation and pek�alties. J <br /> Signature '� 1 �-� Date -7-2c) - 2 <br /> -"� e Z j <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name_rUt EV106=t:Q /FA# <br /> Address 9-0 P I C(gym,} Z Bus. Phone <br /> Cit ` zip qS05i Owner/Operator IOr kly' tblvaz <br /> Check all appropriate services provided: <br /> p Wastewater disposal 0 3-compartment sink 0 Electrical hook-ups <br /> p Solid waste disposal 0 Food preparation 0 Toilet and handwashing <br /> • Hot & Cold water for cleaning 0 Store refrigerated food 0 Potable water <br /> • Store dry food/supplies 0 Overnight parking [3 Vehicle wash <br /> I, Fre,Z_ hereby state that the information I have provided is current, true and <br /> correct to the b -my knowledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator s to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commi sary owner shall not' the EHD immediately. <br /> Signature tQtr Date 7lT� <br /> WTO 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.sigov.org/ehd <br />