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`=`? SAN 10 A Q U I N Environmental Health Department <br /> 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 /> s � ) <br /> Business Name Lic. Plate# �4 S <br /> Owner/Operator Name S <br /> Business Mailing Address ( � <br /> City StateCA -Zip A�- Q Bus. Ph(MD Zf 2-4� 32.AIt. Ph(2i9)512,-1212_ <br /> `'", e <br /> I, by 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 discontinue , the permit holder must no ' the EHD. Failure to notify this office may result in permit <br /> revocation and penalti <br /> Signatur Date 7W kU <br /> 2. To be completed by COMMISSAR��YOWNER/OPERATOR <br /> m <br /> Commissary Name -ct 6oi5Qr;G A "� FA# <br /> Address 1211 '- +� Jr' Bus. Phone ON)33753663 <br /> City,/ Zip X15351 Owner/Operator C,r,/� J�Drrao ,•„;s5�ry/�G <br /> Check all appropriate services provided: <br /> '014.kii <br /> � , . <br /> Wastewater disposal �/3-com3part ent sink Cr Electrical hook-ups <br /> - olid waste disposal 0 Food preparation L9"-Toilet and handwashing <br /> 13" Hot & Cold water for cleaning Store refrigerated food CV�otable water <br /> 0 Store dry food/supplies ar/Overnight parking D/Vehicle wash <br /> i, /k-k L v; 5 Cu'U z , 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 <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 e. 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 7�%1bts <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 />