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SAN J 0 AQ U I N Environmental Health Department <br /> COUNTY <br /> Greatness gro:vs here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be com leted b APPLICANT <br /> Business Name Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address gu_`g rarduor - <br /> City_!E-,)O�(�State_(5LZip !I�us. Ph. 'ZO�- !qj j- �VAlt. Ph.jDj-Q)J10' 182 <br /> 1, , hereby state that the above information is current,true and correct to <br /> the best of my knowledge qnd 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 p er must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date 7 <br /> [9�0 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 6rJ>C 01�yw, FA# 1 Z3 45 9 4 <br /> Address '511 U\) . (,0 of lq, ! - Bus. Phone <br /> City W Zip l 5�7g `410 Owner/Operator <br /> Check all appropriate services provided: <br /> i Wastewater disposal 4-3-compartment <br /> sink © Electrical hook-ups <br /> p Solid waste disposal 13 Food preparation © Toilet and handwashing <br /> Hot & Cold water for cleaning (3 Store refrigerated food © Potable water <br /> 13 Store dry food/supplies 0 Overnight parking E3 Vehicle wash <br /> 1, 5 pS �^ \2,< , 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,!� ify th ediately. <br /> Signature Date 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 /> V <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 />