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JAN 10 A Q U I N Environmental Health Department <br /> "Al COUNTY-- <br /> `''It `' Greatness grows 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 MA r GA 's'' 4 2 Lic. Plate# <br /> Owner/Operator Name ('1 I 4 W 5 r3O lel- n U S <br /> Business Mailing Address 161 Ll 2 <br /> City S �/1 State(A Zip q52()LP Bus. Ph. Alt. Ph. <br /> I, C1 k Gd 15 130�1/4 j Z15 , 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 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ItL SU FA# <br /> Address , S. A1('DCN W � Bus. Phoneme �— S'�� i y� <br /> City 5 6ykZip Owner/Operator <br /> Check all appropriate services provided: <br /> ®^Wastewater disposal 10 3-compartment sink 4rElectrical hook-ups <br /> a Solid waste disposal to Food preparation Toilet and handwashing <br /> 9 Hot & Cold water for cleaning 16 Store refrigerated food Potable water <br /> WSto dry food/supplies Overnight parking Vehicle wash <br /> 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 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 ��T���j <br /> 3. To be completed by the ENV 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />