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SAN�JOAQUIN p <br /> .`° Environmental Health Department <br /> --COUNTY- <br /> 4 OF0 <br /> •--COUNTY4OF0 Greotness grows 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 raC6< (C 'wo _Lic. Plate# �ce p2 <br /> Owner/Operator Name /I'//- �n7_�"/jwm <br /> Business Mailing Address V6c, 1/9 <br /> City Larli^ State C 4 Zip Bus. Ph. Alt. Ph. <br /> 1,4 ZaT d �o�t?�, ��2 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 penalti <br /> Signature Date 2— /�— 2,,:Q2,_ <br /> 2..To becoria` letedb COMMISSARY OWNER/OPERATQR­, : <br /> Commissary Name GrS> �°� FA# L> <br /> Address (0 ZO S S 6-CY4��to r F Bus. Phone 9) 92 7L, E5 o� <br /> City L e)l't ` Zip '15 290 Owner/Operator Aja44Kel OG1�tCtGt <br /> Check all appropriate services provided: <br /> Wastewater disposall3f�-compartment sink M Electrical hook-ups <br /> � s�olid waste disposal �d'Food preparation 0-'Toilet and handwashing <br /> ' t& Cold water for cleaning tore refrigerated food ®'Potable water <br /> 0"/HoStore dry food/supplies 0-6 y <br /> vernight parking 'Vpehicle wash <br /> I, 4--f— , 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 ��� e g _ Date <br /> 3 Tkb'kcom etec�.' �h l V t EAI ;H: ca, i t <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 />