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!4 SAN J FAQ U I N Environmental Health Department <br /> 114 COUNTY --- <br /> 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 U GWOS `I ARMU M ISV6128 Lic. Plate# 4QV841� <br /> Owner/Operator Name AM L, �Symm <br /> Business Mailing Address 5-b S ]b St @Amn rr�� <br /> CityS D"R State� Zip `LO Bus. Ph. EA• 2_4 jL41q Alt. Ph.Q M"I <br /> I,IVA , ESOACA , 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 1 Y q" Date � ' S ' <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name / FA# <br /> Address f r Bus. Phone <br /> City Zip Y Owner/Operator / <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink Ig- Electrical hook-ups <br /> Solid waste disposal 0 Food preparation �Y Toilet and handwashing <br /> [,d Hot & Cold water for cleaning 0 Store refrigerated food EX Potable water <br /> 0 Store dry food/supplies Kovernight parking q Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the est 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 no •f t the EFO im is ly. <br /> Signature Date 7— 2�`21 <br /> 3. To be <br /> completed by the ENV ALTH jurisdiction outside of San Joa in 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 />