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, Environmental Health Department <br /> S A N ;10 A Q U I N <br /> COUNTY <br /> Greotness grows hers. <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 r Lic.Plate# ���f q �Iz <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City Statec , ip�, Bus. Ph. :�CA- ;��I It. Ph. <br /> r , L hereby state that the above information is current,true and correct to <br /> the est of m knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, nd San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary i continued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and I�nalties, <br /> 12— <br /> Signature . A vu Date5 4 <br /> 2. To b c Mplet4by COMMISSARY OWNER/OPERATOR <br /> Commissary Name >� ► of G; y j c < t= e Irl FA# <br /> Address �`/1 Z- i r\1 R. <br /> Bus. Phone <br /> '0 <br /> City %_ <'j��'�c�s� Zip .f� �� S�" SOwner/Operator A C4 0 <br /> Check all appropriate services provided: O <br /> 0NZ <br /> p Wastewater disposal E3 3-compartment sink Electrical hook-ups m G1 <br /> p Solid waste disposal E3 Food preparation Toilet and handwashing (D C O <br /> Z <br /> Hot & Cold water for cleaning Store refrigerated food [3 Potable water Z 0 <br /> ❑ Store dry food/supplies Overnight parking d Vehicle wash > � 0 <br /> I hereby state that the information I have provided is current, true andUl G M <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility R1 D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, thein T� <br /> commissary owner shall notify the EHD immediately. <br /> Signature � �- -, %„ f� ,; Date <br /> 3.76 be comp1eted-b the ENV HEALTH 'udsdiction outside:of,San.Joa uiln`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 /> k <br />