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SAN JOAQUIN <br /> <br />Environmental Health Department <br />Greatness grows her , <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 -The &frizz-1 y <br />Owner/Operator Name Sok \UoAdp 06(voCk.— ac.4 ie r re. a. <br />Business Mailing Address .3(3(') Pd ytetr) LJ.)cxy 9 u <br />City Mocies + 0 state('A zipq5.35g Bus. P <br />I ,ScAN Uarl or- ne0.0.61 /4 u crrezi , 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 penalties. <br />Lic. Plate # 6q 757)(L <br />o <br /> Alt. Ph. <br />Signature Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name CZ_ t\I e I FA# <br />Address-1_0 Pr? / 7v) 1.,,t) cLy Bus. Phone ,,,7e) 54// /71,g <br />City A9de5-1—‘9 Zip 95 / Owner/Operator ci C9,5)e- r-c/ <br />Check all appropriate services provided: <br />2Kstewater disposal Eri-compartment sink 041ectrical hook-ups <br />Eiolid waste disposal 01-Ood preparation Orfoilet and handwashing <br />IZIot & Cold water for cleaning Etitore refrigerated food Faotable water <br />rtitore dry food/supNies EK-:vernight parking Ok/ehicle wash <br />—MSc_ , 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 •mply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary r shall notify the ,,H9 immediately. <br />Signature pate 11 .?7 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in CI `A.\ S (C. 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. PI ase notify EHD if the stJ us of their operating permit changes. <br />REHS Signature Date <br /> <br />1 zb 1212.4 <br /> <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 />ygls 00 2-1S