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SAN oQQ N Environmental Health Department <br /> --COU N7Y------ �� ��ZSS� � <br /> Greorness rr)r }ier�e. e-'_ <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 b APPLICANT <br /> Business Name,L - ,5 &\'��O;A�ye S Lic. Plate <br /> Owner/Operator Name C \UW V-, <br /> Business Mailing Address _2+43Z. J(tuiW(AIY 5 <br /> City : fL ✓\ StateZip QSZ&&, Bus. Ph. <br /> Aft. Ph. <br /> I, hereby state that the above information is current, true and correct to <br /> the best of my knowledge and agree to utilize my apotoved 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, t4 e permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature � Date l L1'2� <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name bA�i GLn � FA# <br /> Address 1- 9b �, . } �1',F'c�•l--�— a Bus. Phone q-57-) % — i Y C, L, <br /> City +)- ) Cr,`k7jaA Zip cl CZE✓ L Owner/Operator 24e_.S Q4 b i U <br /> Check all appropriate services provided: <br /> a Wastewater disposal 3-compartment sink PrElectrical hook-ups <br /> 10 Solid waste disposal Food preparation UrToilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food 0 Potable water <br /> 0(Store dry food/supplies Overnight parking Vvehicie wash <br /> I, S, LCA , 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 Date Y Z <br /> 3. To be 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 />