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t SAN JOAQUIN a <br /> Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility • Caterer <br /> Complete sections 7 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be completed b APPLICANT <br /> Business Name_ I �►f�( � c�'Pe Gtu1�GS �,�� Lic. Plate# <br /> Owner/Operator Name t ( Lo <br /> Business Mailing Address �� t Qj oo v1 <br /> City 1C. 1't StateZip�5�p`�Bus. Ph. Zo`t S9 �3 obi)_ Alt. Ph. <br /> I, 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;th� permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and Ities.' <br /> Signature ` Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Cp\0Lc..�k,0e\ <br /> Address Bus. Phone <br /> City Zip q S2o(� Owner/Operator CVn e> <br /> Check all appropriate services provided: <br /> Wastewater disposal 9 3-compartment sink 0/61ectrical hook-ups <br /> m-"Solid waste disposal mood preparation ® i' olet and handwashing <br /> 6" ®S <br /> Hot & Cold water for cleaning tore refrigerated food 9� Potable water <br /> tore dry food/supplies pleovemi ht parlsing %,VeHth—,�h <br /> 1, 7::�QQ , tieZ , 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 own hall notify e EHD immediately. <br /> Signature <br /> Date Ll - 2q <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 /> PP 25DN 3� <br />