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SAN..JOAQUIN Environmental Health Department <br /> " Li i COUNTY <br /> Greatness )iasys <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 /> t <br /> Business Name 1 rr� 5� 1 t L,st.... �--L— Lic.Plate# (, <br /> Owner/Operator Name J I S A wt L(1u( <br /> Business Mailing Address_/Cf 6 Z C t <br /> City State L'IN Zip Bus. Ph. (lam V 4 _Si ej q-_Alt. Ph. <br /> L� , 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 and ti <br /> r; <br /> Signature p Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Z' � �CL�Gi.i r � en f'1' FA# <br /> �>Z � 4c �Y� a L Sus. Phone Zo-- Z Z <br /> Address � l' :.�-+ � � <br /> City_ e-)Dr- Zip ` 5 4VO Owner/Operator <br /> Check all appropriate services provided: <br /> IVastewater disposal 1 ' compartment sink Electrical hook-ups <br /> i <br /> f)-'!!�clid waste disposal ® ood preparation CI-Ioilet and handwashing <br /> �ot & Cold water for cleaning t e refrigerated food M 'otable water <br /> [3'�ore dry food/supplies Overnight parking Eli-vehicle wash <br /> !, z •�-- 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 conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediately. <br /> - <br /> /��Signature 4 �� '� Date <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 i www.sjgov.org/ehd <br /> i�o 5 LI��H�- <br />