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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> /4�„�' Grc,.tness f71'.covvs here. <br /> COMMISSARY AGREEMEN <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section, <br /> 1. To be completed by APPLICANT <br /> Business Name TG{[ Lic.Plate# `>' <br /> Owner/Operator Name <br /> Business Mailing Address 002- aa4-1 r/c t L/e- <br /> City STD-k � State_A Zip I' Z d Bus. Ph.yu 10 6-E-1`1 Alt. Fn. <br /> I, hereby state that the above information is current,true and correct t, <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 penalbeo. <br /> signature <br /> ,:ol vi 6 c��d : i Date 12- <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name + l, fir nji. %� � r+✓l �► FA# <br /> Address 7 q Vu S � A% (',?c,(' �- f.t,ti Bus. Phone <br /> City Zip Owner/operator f'S � �Q-7/' <br /> Check all appropriate services providea. <br /> I!f Wastewater disposal It( 3-compartment sink IT Electrical hook-ups <br /> J( Solid waste disposal 10 Food preparation tYToilet and handwashing <br /> E Hot&Cold water for cleaning 3`7 Store refrigerated food I$ Potable water <br /> M Store dry food/supplies Overnight parking I:t Vehicle wash <br /> 1. ��-"1 C<-, , hereby state that the information I have provided is current,true and <br /> correct t— o�st of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> )perator 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 /> z - <br /> Signature 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 Da:= <br /> 168 E. Hazelton Avenue I Stockton. California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br /> K 25029-I <br />