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SA N 10AQ U I N Environmental Health Department <br /> �` Il r --COUNTY <br /> � r Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections I and 2. !f your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> -ZP-k Ia '� <br /> Business Name Y Q o 5 f-seS cb c Mu Lic. Plate# <br /> Owner/Operator Name U G e Z <br /> Business Mailing Address , _ Lj �55 C h�Y�?Cep Ind <br /> City S O Y StateC•f _Zip_af 2)5Bus. Ph.[ 51 S A o aMIt. 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, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature , 2 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name C.. { 4 ,+ SQj2P C FA# <br /> Address Y YU Lj Bus. Phone c - 'C — / y6 <br /> City tL Zip YQt,) Owner/Operator <br /> Check all appropriate services provided: <br /> M Wastewater disposal W 3-compartment sink [ (Electrical hook-ups <br /> Ef Solid waste disposal L# Food preparation Toilet and handwashing <br /> 1W Hot& Cold water for cleaning 60 Store refrigerated food Potable water <br /> ET'Store�dry food/supplies 14 Overnight parking EW Vehicle wash <br /> I, b 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 falls to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall noW the EHD immediately. <br /> Signature Date /2-0 <br /> Z <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 END if the status of their operating permit changes- <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />