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SANIIJOAQUIN Environmental Health Department <br /> COUNTY-- -- <br /> GrFKOS212sol <br /> • e•aknEsi growstrcrc. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections 1 and 2. !f your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed b APPLICANT <br /> Business Name N G.rQ o"S vrLic. Plate# <br /> Owner/Operator Name 0Q(:1�7C! LA (I Cc: �� 1 CSC -J <br /> Business Mailing Address 2.2 1) L� D AJ \-) 08K CT <br /> City LA ,LL-SSD State Zip_Cl.S3SS Bus. Ph.R.7 i -� �-_��, `.�/�J�It. Ph.2C)I_Z S-C1 -.-M <br /> 1 <br /> I, CLI QfdQ "V, i, CSS 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 permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalti / <br /> SignatureDate 2 / 1 420 >' <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name l; 6,1 -fF,�c# <br /> Address �1 5 i) A) &Q S7 Bus. Phone Z Oct- Z 1-1 L-�S Z L2 <br /> CitZip Cl r� ; Owner/Operator ( '� 'c =,►l�V /lam /Ji1 <br /> Check all appropriate services provided: <br /> Wastewater disposal Ok 3-compartment sink OV Electrical hook-ups <br /> Solid waste disposal #Food preparation r4'Toilet and handwashing <br /> Hot&Cold water for cleaning )% Store refrigerated food P Potable water <br /> I,$I Store dry food/supplies �jOvernight parking I�Vehicle wash <br /> 1/<-4 r t , 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 con i. ns of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner hall n tify th immediately. / <br /> Signature Date ! l a� 0 <br /> 3. To b om leted 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 j Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />