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SAN JOAQUIN <br />COUNTY <br />Greatness grows here. <br />Environmental Health Department <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 />r 1. To be completed by APPLICANT <br />Business Name a 47 CO 1.er I Y9 <br />Owner/Operator Name t5e.1--- 4) ro fk <br />Busines Mailing A ddress 3 I R roictc)uct <br />City State CAZip CS7_07 Bus. Ph. (209") 5M6 ochla 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 dis snfinued the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name ENID Coc- CO C\r‘Cr‘FA# <br />Address \\CI &L E .oroAcp Bus. Phone <br /><=1.0\ Gstar\cv\c_2, <br />Wastewater disposal <br />Solid waste disposal <br />3v4ot & Cold water for cleaning <br />r3,‘ore dry food/supplies <br />Vi-compartment sink <br />kfood preparation <br />ai/gtore refrigerated food <br />(g/Overnight parking <br />Letlectrical hook-ups <br />ce, Toilet and handwashing <br />arl5otable water <br />YK/ehicle wash <br />I, \ )Cl.c\C\e'Vc--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 sh otify the EHD immediately. <br />Signature Date Z-1 2-402-3- <br />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.gjgov.orgiehd <br />ri?09-1%c361 <br />Lic. Plate # <br />Date 6.4/ /0 7Z5 <br />City .\1 /4-00‘...-c-jr- Zip q S2-0 a Owner/Operator <br />Check all appropriate services provided: