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' <br />SAN JOAQUIN Fle,a0th Deparitm,ent <br /> <br />—COUNTY <br />, <br /> <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 Ef co <br />Owner/Operator Name (C re-7- t/citv, ci <br />Business Mailing Address CC in - (sucl- <br />n„ City ,i0C,iCk•On State CO Zip cc:5.40 7 Bus. Ph114 PhYDF)7/ Q <br />(K) ocirric cd(d.€114-6? 1 )1/4.((a,Cipc"-), 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 END. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature <br />2-:-To completed. by COMMISSARY OWNER/OPERATOR <br />Commissary Name 1-711 rqtx -Ft FA# <br />Address/ f 3 cs- Bus. Phone <br />City Ze jti Zip /c- 6 Owner/Operator (i)A, 'e% <br />ii 3-compartment sink <br />Food preparation <br />a:I Hot & Cold water for cleaning Store refrigerated food <br />commissary owner shall notify the EH immediately. <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 />Store dry food/supplies L.77, Overnight parking <br />41/17,4 <br />, hereby state that the information I have provided is current, true and <br /> Date <br />3-.- To te-toMplete-d by_ the \KHEALTH-jUridiCtion outside-ofSam-JO-attitliri Go: <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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />Lic. Plate #yorya--7 <br />Date <br />2-d 3 Y- )( <br />Check all appropriate services provided: <br />-7 Wastewater disposal <br />7. Solid waste disposal <br />Electrical hook-ups <br />Toilet and handwashing <br />M Potable water <br />Vehicle wash <br />Signature <br />7n-\i?>\(9c\