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SANs10A0 U I N Environmental Health Department <br /> �Y1 —COUNTY <br /> Greatness 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 /> 1. To be completed by APPLICANT <br /> Business Name t5 C(- <br /> ,�1U A G Lic. Plate# C' Z <br /> Owner/Operator Name moo' — A, <br /> Business Mailing Address )(-IQ We S�t S <br /> Cit•-y� T t,t(L State (PZip , Bus. Ph. 0- 3Z) _Alt. Ph. <br /> I, K(-A nit ��lOfZ_ , hereby state that the above information is current,true and correct to <br /> the best of my knowte g�a a 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 isc tinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a e lties. _ <br /> Signature Date Z Z S <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Onloo iy� . ' '1►' ti` c G FA# rr <br /> Address i -I 'l 1 5 • 0 f)W I/ l Bus. Phone <br /> City SQ U�JCIGA� Zip U Owner/Operator 1 <br /> Check all appropriate services provided: <br /> Wastewater disposal IR 3-compartment sink ❑ Electrical hook-ups <br /> - Solid waste disposal 0 Food preparation ;C'Toilet and handwashing <br /> Hot& Cold water for cleaning ❑ Store refrigerated food P Potable water <br /> l❑ Store dry food/suf�pplies 0 Overnight parking 1P Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct t6 the best of y kn ledge,and meets the California Health&Safety Code requirements. if the food facility <br /> operator fails to com with a conditions of this agreement, or if this agreement is modified'or cancelled, the <br /> commissary ow r steal h EHD immediately. <br /> Signature Date <br /> 3. To e m feted 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 EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 I www.sjgov.org/ehd <br /> 1K(z5 z 6'Di?> <br />