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SAN J O AQ U I N Environmental Health Department <br /> --COU NTY - <br /> :r:_ '< grows her.:.. <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 7 <br /> Business Name ::�3 4C7 cz Lic. Plate# tt��: V <br /> T <br /> Owner/Operator Name C-E- C� <br /> Business Mailing Address GUMC <br /> City State Zip ius. Ph. t. Ph. <br /> 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 holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature (� 1,// 3 Date / <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name /" K'5" FA# <br /> Address lZ\ J; ­-�"' st Bus. Phone (,Zo>)3-3z <br /> City Q O'l'51-0 Zip�5,�51 Ow r/Operator /U,//;ate, <br /> Check all appropriate services provided: <br /> 131"Wastewater disposal 0-*'3-compartment sink Electrical hook-ups <br /> olid waste disposal Toilet and handwashing <br /> © Hot & Cold water for cleaningod 0-'Vehicle <br /> water� <br /> 6f Overnight parking © Vehicle wash <br /> 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 owner shall notify the EHD immediately. <br /> Signature Date 9////Z3 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in SkUAAtC 10AS 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 />