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SAN JoAouIN <br />Environmental Health Department <br />COUNTY <br />Greatness 9t*is 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 />To be completed by APPLICANT <br />Business Name f ,Cot b/-05 0 <br />Owner/Operator Name E r ..car; ex no <br /> <br />Lic. Plate # g 2.-zgef 37 <br /> <br />Business Mailing Address 3(1 5S [Cri ck IV( Joh Sir <br />City (S-eoci-eil Statee4 Zip '9,r?...,05— Bus. Ph. 7_0"--29 Yqvg Alt. Ph. <br />I, • • • • kA 60,t/A .c..o, 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 a2:1 penalties. <br />Signature E k4 OE" 4.) Date oi-17 - <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name CC' // enl'‘t 61, lej vt.,) FA# <br />Address c-,. tAj Bus. Phone Z0 Cl 7 1 L.6, <br />City 540(.14 Zip el cte, 7 Owner/Operator <br />Check all appropriate services provided: <br />Et Wastewater disposal <br /> <br />3-compartment sink <br /> <br />Electrical hook-ups <br />I(Solid waste disposal <br /> <br />I .1 Food preparation <br /> d Toilet and handwashing <br />Hot & Cold water for cleaning ,4 Store refrigerated food <br /> <br />CT Potable water <br />a Store dry food/supplies ix Overnight parking <br /> a Vehicle wash <br />I, , hereby state that the information I have provided is current, true and <br />correct to the est 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 <br />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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br /> <br />Date <br />