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' , . . <br /> - . <br /> Environmental— HeaUth Department <br /> � 8k " 0 ` = Kj <br /> / ~ <br /> ----COUNTY--- <br /> - <br /> 0:'_ � ^'` Grootness gro�vs 6en� <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * CGt8P8[ <br /> Complete sections Yand 2 If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> BusineasN <br /> Ovvner/OpenytorNonn ' <br /> Business Mailing Address <br /> City c k State C o Zi Bus. Ph. t. Ph <br /> | . hereby state that the above information iocurrent,true and correct to <br /> the best of my knowledge and agnea to utilize my approved commissary in accordance with California Health & <br /> Safety Code. and Sun Joaquin County Environmental Health Department (EHO) requirements, If the use of the <br /> commissary i di oonti d the permit holder u tnotify thEHD Failure to n tify this office |t in permit <br /> revocation and pen ies <br /> SinniAtijrp Date 7-7-, <br /> [2. To be—completed by COMMISSARY OWNER/C)PERATOR <br /> Commissary Name /1- //j�/ FA# <br /> Address—/ Bus. Phone 9-1) <br /> Cit __Zip !�V/)_Owner/Operator <br /> Check all appropriate services provided: <br /> IWWastewater disposal 13 3-compartment sink 1R_ Electrical hook-ups <br /> qfSolid waste disposal 0 Food preparation ITToi|etand handvvashing <br /> hmfHot & Cold water for cleaning E3 Store refrigerated food E3 Potable water <br /> E3 Store dry food/supplies E3 Overnight parking 1W Vehicle wash <br /> hereby state that the information | have provided iocurrent,true and <br /> correct tothe bastofmyknowledge,and meets the California Health&Safety Code requirements. (fthe food facility <br /> operator foUo to comply with the conditions of this agmement, or if this agreement is modified or cancelled, the <br /> Signature Date Z_-:�� Zi <br /> F3. To be completed by the EWqPALTH jurisOictipin outside of San Joa uin 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 EHDifthe status oftheir operating permit changes. <br /> REHS Signature e <br /> 1O88E. Hazelton Avenue I Stockton, California Q52O51 T 209468-34201 F 209 464-0138 1vmmm.sjgov.org/ehd <br />