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U;"c°�, SAN JOAQUIN p <br /> �., z, Environmental Health Department <br /> N i4b �' = {; ----COUNT Y <br /> Greotness grows here. <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 /> 1 To be completed by APPLICANT <br /> Y �m <br /> Business Name I � L �(Z— `ti"c. Plate# <br /> Owner/Operator Name l <br /> Business Mailing Address �/ .—s Gr�yy <br /> City Ci *n/State:�4Zip SZv Bus. P h 2 0.9 It. Ph. <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 anpenallttie <br /> Signature p'-�2� �d � ��'' � Date ��l� V <br /> 2 To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Q Q 10Q C kjffjZiaH I k VCk. CO 6r- , FA# ii -- <br /> Address no U 0 0A) C)-7 Bus. Phone, Q � 2 5 q 1T <br /> city 1)10G�10/0 Zip Owner/Operator \�®bk fbu _ i ant—d'-) <br /> Check all appropriate services provided: <br /> Wastewater disposal )' 3-compartment sink Electrical hook-ups <br /> RSolid waste disposal 1j Food preparation Toilet and handwashing <br /> Lr Hot& Cold water for cleaning Store refrigerated food ;ehicle <br /> otable water <br /> Stor dry food/supplie �j► Overnight parking wash <br /> V\ hereby state that the information I have provided is current,true and <br /> correct t the be t of my knowledg ,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with t onditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ow r sh oti a EHD immediately. A91 Signature Date l <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 i T 209 468-3420 i F 209 464-0138 1 www.sjgov.org/ehd <br /> jR0S3� - <br />