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SAN J O A Q U I N Environmental Health Department <br /> COUNTY--- <br /> Greorn grows <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 I <br /> Business Name C�ZI1 1s 0 6) o L Lic. Plate# `, U9f-7Z Z <br /> Owner/Operator Name M ofk?10- 00 N*-IT <br /> Bus' ss Mailing Address �512q <br /> city Jl of) State CA Zip �1 ?-���Bus. Ph. Alt. Ph. <br /> I, N-o 1 �,O(A P D , 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 isc ntinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and alties. <br /> Signature GI`s Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name k-)kilo�j CIrC kjAjb ItUtK CcVjER FA# <br /> Address 1717 S• lJ N I UY J S1 Bus. Phone C 2,00t u 1 �2 — <br /> city Sno cr,-t ) Zip 9 .17a0 (o Owner/Operator API• y1440 S <br /> Check all appropriate services provided: U/�614 OAJVI <br /> wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> olid waste disposal ❑ Food preparation 5 Toilet and handwashing <br /> Z Hot & Cold water for cleaning ❑ Store refrigerated food 0 Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking 17 Vehicle wash <br /> &J._ 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/ 102��3 <br /> ahl <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San JoaquinC <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 />