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SANGIOAQUIN <br /> • �G`` -�-°°4 Environmental Health Department <br /> COUNTY <br /> Creotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 9 and 2_ if your commissary is located outside of San Joaquin County also complete section 3. <br /> To be corn feted b APPLICANT o <br /> Business Name �� � �/� l ms r Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address 39 /�O�hl��4d`/ <br /> City �U``� 5tateC Zip 6� Bus, Ph!?2 S J I"L�lt. 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 penalf <br /> Signature Date <br /> �S <br /> 2. To be`eorn. feted bV,COMMISSARY OWNER/OPERATOR <br /> Commissary Name G� 4 d"u, �, FA# <br /> '33 R-V�-t '� S Bus. Phone Y� <br /> Address — - <br /> City �`�`� Zip - Owner/Operator <br /> Check all appropriate services provided: <br /> ® Wastewater disposal ® 3-compartment sink ® Electrical hook-ups <br /> ® Solid waste disposal ® Food preparation ® Toilet and handwashing <br /> ® Hot & Cold water for cleaning ® Store refrigerated food ® Potable water <br /> ® Store dry foodlsupplies ® Overnight parking ® Vehicle wash <br /> 1 , 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 e <br /> commissary owner shall notify the EHD immediately. <br /> Signature � � —�� `� L� ^k" ` 66Date <br /> 4 V <br /> ,To be cor `1etd`b. . I1e ENV.HEALTHY'i.irisdltran'outstale;ofi�SanJa ul;n F o'. <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 209 446`8-3420 l F 209 464-0138 l www.sjgov.org/ehd <br /> / S <br />