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SAN J OA Q U i N Environmental Health Department <br /> COUNTY Greatness grows hese. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 �s� 01C nQ Scabo,r Lic. Plate# <br /> Owner/Operator Name 1) c_- ,rc� ftA(s.6v-,U C" - C <br /> Business Mailing Address &Y— too Ir , Lo, <br /> vu- <br /> city State O } Zip GS 311 Bus. Ph.(2o`+�„J.� - l l '�ZAlt. Ph. f `i 3 --7 ty <br /> 1, - , hereby state that the above information is current, true and correct to <br /> the b t of my knowledge and Aree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EMD) requirements. If the use of the <br /> commissary is discontinued, the it holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalti s. <br /> Signature Date 3 <br /> 2. To be com leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name UA i L 1 0. FA# <br /> Address 2cl00 `C��S - I�GrC��ht;, L�� Bus. Phone (Loci) 76 <br /> City SAcc.'L'r'-6C) Zip_ C-15 _b S Owner/Operator at <br /> Check all appropriate services provided: <br /> [+ Wastewater disposal b( 3-compartment sink )<Electrical hook-ups <br /> Solid waste disposal © Food preparation Toilet and handwashing <br /> I2q Hot & Cold water for cleaning [3 Store refrigerated food Potable water <br /> ® tore dry foodisupplies 1%Overnight parking Vehicle wash <br /> 1, OnriY/.4hereby 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 omply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissaown r shall notify th immediately. <br /> Signature a Date 3 � <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> '>�'0S 1 �22� <br />