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SAN 10AQUIN Environmental Health Department <br /> L-6! " :`' -----COUNTY_--- <br /> Grootness grows her, <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 ZZ f__7 T-A, Lic. Plate# L4 VX IS �B_ <br /> Owner/Operator Name A)1:8 a S) i 0 G 8 <br /> Business Mailing Address I I �6 SI <br /> City 1r hA1'fi'01 StateC6—Zip 3_l Bus. Ph. 2_C)c L B I (�l LL1ZAIt. Ph. <br /> 1, � -�..�; �^ hereby state that the above information is current, true and correct to <br /> the best of my knowledge ang 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 Itips. <br /> Signature Date /2'1 S —z-; <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ��`� \} Q. �1.� FA#r <br /> Address Bus. Phone P05 <br /> City-440— n) zip Owner/Operator )I��144 rlL[>w i-�'Zy <br /> Check all appropriate services provided: <br /> Wastewater disposal Of 3-compartment sink Electrical hook-ups <br /> Solid waste disposal 0 Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning 0 Store refrigerated food Potable water <br /> Store dry food/supplies Overnight parking Vehicle wash <br /> lx�A�f = ( C✓ , 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 omply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa ow shall notify the E D immediately. c/ <br /> Signatur Date 1 �� <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />