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SAN J OAQ U IN Environmental Health Department <br /> COUNTY - <br /> Greatness gra``.-­ f111.11 <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 p <br /> Business Name JAS SCC�)OpS Lic. Plate# <br /> Owner/Operator Name J P—t4t,1( f::EGSTA3( ILL-0 <br /> Business Mailing Address -7rb_I PF_-2>(3Ly_ wP-*-1 <br /> City MANTEcA State CA ZipgS33(­ Bus. Ph. 5ty-570q-01 WAlt. Ph. W&, <br /> I, jet'tt.-tFC?_ t3l L-L-0 , 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 Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the permit hold must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date Z/ 2-0Z3 <br /> 2. To be completM by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ? 'I Ck I(]1 Sy b —1 C'TA-00 ,-7 FA# <br /> Address _3c{l-a Bus. Phone aacA -c''I�Ay-i ?�r�7 <br /> City S'?-4 Cid'%o r✓" Zip !Q C1 S-ti,o-S Ow& o/perator SCA1-nc,rY� SC-1 i n M <br /> Check all appropriate services provided: O Z <br /> [3 Wastewater disposal ❑ 3-compartment sink Electrical hook-ups Z N Z <br /> [3 Solid waste disposal ❑ Food preparation � Toilet and handwashing � 171 <br /> ❑ Hot & Cold water for cleaning� Store refrigerated food ❑ Potable water Z 3 O <br /> Z <br /> ❑ Store dry food/supplies Overnight parking ❑ Vehicle wash n M M <br /> I, �c1i�a w� SG f hereby state that the information I have provided is current, true andD 0 <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility (A < <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the C 111 D <br /> commissary owner shall notify the EHD immediately. N 1C <br /> Signature - r , .r < 5�,�-; Date E /Z - 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 />