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P��sy �1��SQN :��QQ� IN Environmental Health <br /> Department <br /> ---C O U N T Y----- <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 f z(4 I Lic. Platek. 1VM 595 6 <br /> Owner/Operator Name_ f 60410ty- (�11141 <br /> Business Mailing Address 'AI M ul 1 miso Icg CA <br /> City Ya State (0 963711 Bus. Ph. S►o SIZ 6173 Alt. Ph. <br /> I, �-f V�Ocg_ [y)S k 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 en tie <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR . <br /> j <br /> Commissary Name 1 i C�)f A i�. C � 5 �_FA# <br /> Address tr'!2dr Bus. Phone 20,q- <br /> City G:L12 ,V-�aA Zip Q C,ZO 6_Owner/Operator S <br /> Check all appropriate services provided: <br /> 10 Wastewater disposal E�' 3-compartment sink Electrical hook-ups <br /> 14 Solid waste disposal M Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning R Store refrigerated food [W Potable water <br /> 10 Store dry food/supplies Ir Overnight parking Vehicle wash <br /> 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 <br /> completed by the ENV HEALTH jurisdiction outside of San Joaquin 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 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />