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SAN JOAQUIN Environmental Health Department <br /> _.--COUNTY - <br /> (,reofm.,ss <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 J <br /> Business Name G iS �� I G C 1 LL Lic. Plate# y�13/ -7zZ- <br /> Owner/Operator Name h� i^:Itis �1af�Tt� <br /> Busiess Mailing Address <br /> City �M[O N StateCA- Zip O h'I FI Bus. Ph. '�>(G� W Alt. Ph. <br /> 1, 9A-�C�k - Citi ' , 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 �l I <br /> Signature I�e`ci Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name;,401 <br /> kWKIC Pf') Mh06WEnT FA# <br /> Address j �7i t;+�iKTa � \ Bus. Phon tp) � lmq <br /> City Wo Zip �� Owner/Operator ' <br /> Check all appropriate services provided: <br /> ❑ Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ St9fe refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies )2'overnight parking ❑ Vehicle wash <br /> 1, Vw�h /1— , 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 comp) with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner 01 note e E immediately. <br /> Signature Date `� -171- 2 3 <br /> 3. To be completed by the NV HEALTH jurisdiction 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 EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />