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SAN 10AQ U I N Environmental Health Department <br /> ----COU N T Y-- <br /> Myrootness , .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 QLsu;� Mt r10 CkYO CgTT h Lic. Plate# T5 I ,3 <br /> Owner/Operator Name <br /> Business <br /> rr Mailing Address '2.C1 jj(V <br /> City StateZipj Bus. Ph. Alt. Ph. Qo S <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 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 Date % /Uf OC)Z 5 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name&X.I i Guff Y\1(.. ( .Aer»xI Su jo I FA# <br /> Address 2—Y VO S . wc,h Bus. Phone I,&`l T t L <br /> City L/1 Zip _ _L0 , Owner/Operator <br /> Check all appropriate services provided: <br /> Ig Wastewater disposal O 3-compartment sink Electrical hook-ups <br /> Q Solid waste disposal 93 Food preparation Toilet and handwashing <br /> 4 Hot & Cold water for cleaning 4, Store refrigerated food Potable water <br /> 11 Store dry food/supplies Vj Overnight parking [7( Vehicle wash <br /> I, &:k�e-`� 52( /r,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 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 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 />