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` SAN 10AQUIN Environmental Health Department <br /> COU N T Y <br /> ` Greatness rows 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 :::�s Lic. Plate# 9 <br /> c <br /> Owner/Operator Name4:41,-"r, Y �J' C c— <br /> Business Mailing Address (��� ( // <br /> City StateaZip b us. Ph. r Fi t. Ph. <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 Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the pirmit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature S Date 4 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary NameA.<'5 4'54G�eh ALL FA# <br /> Address Oaf\ 5, 4""' 6t Bus. Phone bac)9)3—A -366:5 <br /> City 'Q Zip 8535) Ow r/Operator <br /> Check all appropriate services provided: <br /> [Wastewater disposal 1121/3-compartment sink Q'Electrical hook-ups <br /> olid waste disposal Toilet and handwashing <br /> © Hot & Cold water for cleaning Food Q Potable water <br /> Overnight parking 0ehicle wash <br /> I, arlL Lo,,> (,al , 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 9YIIIZ3 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in Sk"QMIc 1"S 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 l 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 />