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1r or <br /> sttuld <br />SAN)JOAQUIN <br />COUNTY— <br />Greatness grows her <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 />To be completed by APPLICANT <br />Business Name E (21 (-) I I 1-1 c (-) Lic. Plate # 5 7 2 7 <br />Owner/Operator Name )9- / I7 C ; cx pirte) <br />Business Mailin9 Address ?7 77 /goo- VarA Co c c <br />City C kckkk k State cm Zip 7C.2i2_Bus. Ph. *)9 q 62 - P/245kIt. 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 and pen <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />1, <br />Date <br />Commissary Name Ei <br /> <br />gustie_115 - <br />Address ,,225/ E <br />city57Indl„, CA zip q3-2 05- <br />Check all appropriate services provided: <br />Bus. Phone Go/ <br />Owner/Operator <br />Wastewater disposal <br />1:1 Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />I, aCiCk 606frup , 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 <br />Signature <br />hall notify HD immediately. <br />Date DEC - 202,S <br /> <br />r3. 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. PIP.,98epptify EHD if he status of their operating permit changes. <br />RENS 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 />Y OS 3S I g <br />3-compartment sink <br /> <br />O Electrical hook-ups <br />Food preparation <br /> O Toilet and handwashing <br />Store refrigerated food <br /> <br />O Potable water <br />Ea Overnight parking <br /> O Vehicle wash