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4 <br /> SANsd0A0UIN Environmental Health Department <br /> COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 1 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 +::-- Lic. Plate#q-2-,2�iGL <br /> 0 <br /> Owner/Operator Name 4 La <br /> Business Mailing Address [ <br /> City pp 1 State(-Arip 0 Bus. Ph. Alt. Ph. <br /> I, \ t�_� r1 I� N n V-CA L'eCS , 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 Date l I Zn Z(5Z.5 <br /> 2. To be completed b + �COMMISSARY9OWNERIOPERATOR <br /> Commissary Name /rC9 r!, r4 Zip FA# 6)0o�7 <br /> Address Q &'11qn1 fi—Ivl. Bus. Phone a o0 - Z I <br /> City Zip 3,rp Owner/Operator �5&yfe! nat LF_� <br /> Check all appropriate services provided: �/ <br /> [Wastewater disposal 13 3-compartment sink Q Electrical hook-ups <br /> (Solid waste disposal C] Food preparation Toilet and handwashing <br /> 13 Hot & Cold water for cleaning [3 Store refrigerated food Potable water <br /> 13 Store dry food/supplies Overnight parking Vehicle wash <br /> i, /Q , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, nd 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 owner sh notify the EH immediately. <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 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 />