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I S J OA Q U I N <br /> CUNTYp <br /> Environmental Health Department <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 /> L1. To comletp ed by APPLICANT <br /> Business Name TGt CO , <br /> S }a` Ly 11)aC1-( Lic.Plate# `I/� P -p U L <br /> Owner/Operator Name -e-dC)2�n 6­76,72.akL <br /> Business MailingAdd <br /> II__ ress j 1 ivy l>tr s r <br /> City S C f� ✓1 State!21 Zip�_Bus. Ph. <br /> Alt. Ph. Zd a! �,tf� `;6 <br /> hereby state that the above information is current,true and correct to <br /> the best of my and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, s in County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and r- <br /> Signature �- <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName FA# <br /> ry Address_ S ,-' i ' Bus. Phoned <br /> City zo,. 1 Zip Owner/Operator /l <br /> Check all appropriate services provided: <br /> Wastewater disposal i�z"3-compartment sink 5�f Electrical hook-ups <br /> EZ Solid waste disposal Food preparation Z Toilet and handwashing <br /> a�Hot& Cold water for cleaning F7 Store refrigerated food 0• Potable water <br /> J Store dry food/supplies / !X Overnight parking 3 Vehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correct to the best of my knowled ,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with th conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the HD/" jpdiately. <br /> Signature__ Date--- <br /> r — <br /> 3. To be com leted_b ffie _____ EALTH 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 /> wl <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/elid <br />