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2 Vii` SAN J O A Q U I N Environmental Health Department <br /> --COUNTY <br /> Greatness grovvs here, <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 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 6_0 A ��Al v r C� Lic.Plate# <br /> Owner/Operator Name <br /> Business Mailing Address 3 ( r h/d OCA y R—d q <br /> City l/ Stat��Zip q�2;&us. Ph.2-O f-579f'.7(J/Alt. Ph. <br /> I z i - , hereby stbte that the above information is current,true and correct to <br /> the best of my knowledge and gree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joa i County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discont' ue t e permit holder must notify the EHD. Failure to notify this off' <br /> result in permit <br /> revocation an pena s 'sDate �^-' <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name -f"rr'E);y4o FA# <br /> Address 6 2' G) a4 --fe F' Bus. Phones <br /> City 4-ellp r' Zip q 5 ZYef Owner/Operator lctknk" <br /> Check all appropriate services provided::/ <br /> wastewater disposal ® 3-compartment sink P/6ectrical hook-ups <br /> jj <br /> lid waste disposal JN Food preparation Wlroilet and handwashing <br /> Hot & Cold water for cleaning a Store refrigerated food P-15"otable water <br /> (jYS�ore dry food/supplies Overnight parking hicle wash <br /> I, k 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 �,�vQ Date /2 3 <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />