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SAN -10AQ U I N Environmental Health Department <br /> - <br /> COUNTY - <br /> COMMISSARY <br /> OUNTY -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 com teted by APPLICANT <br /> Business Name�T�n--I GK Z G D Lic. Plate# qSM —7Q S e <br /> Owner/Operator Name C.yn i S e m I t I VL ')00 c N <br /> Business Mailing Address 10 P(2- <br /> Cit <br /> City '�(-pState CLZip X21 Bus. Ph. Alt. Ph. 26G /S <br /> 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 penalties. r l <br /> Signatur Date V 3 — 2-Z— 70 2 q <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L 0. C'C)me,(-C- c."1 C-o�Q . FA# <br /> Address i ,tea wc�� Bus. Phone Zocl - 'I(04 - +570 <br /> City "4Zcjyc'-� Zip 1152bS Owner/Operator q. 2, '(chip,` fAR nc+- <br /> Check all appropriate services provided: <br /> Wastewater disposal )!�3-compartment sink Ad Electrical hook-ups <br /> Solid waste disposal 0 Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning 0 Store refrigerated food A� Potable water <br /> 0 Store dry food/supplies .1A Overnight parking Ix Vehicle wash <br /> 1, V1,G r CLn 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 sh notify the EHD immediately. <br /> Signature <br /> 2- ---- Date 03 - 22 2 4 2�{ <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 />