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SANIJOAQUIN Environmental Health Department <br /> COUNTY <br /> ' E Greatness grows he.- <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 /> na <br /> Business Name , .Got Lic. Plate# �1 V <br /> Owner/Operator Name � c <br /> Business Mailing Address <br /> Cit StatZA Zip -IZ) Bus. PInje) AIt. Phr� 5`Lvl-QS (JCS <br /> I, o -;7— , 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 ��?/ice ��,� Date c O ' 7-5 <br /> 2,. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L(;, C O W'Q'r ck, u Ili. FA# <br /> Address_ 21cko 0 6" - kikur r Bus. Phone C 20C ] L((Q 1A— 4'S 7 0 <br /> City �r'6" r Zip cl S ZO Owner/Operator�� ��t �Y'rl i� <br /> Check all appropriate services provided: <br /> 13 Wastewater disposal G' 3-compartment sink 12 Electrical hook-ups <br /> [3 Solid waste disposal 0 Food preparation 6 Toilet and handwashing <br /> 0 Hot& Cold water for cleaning 0 Store refrigerated food 19 Potable water <br /> 0 `fie dry food/ upplies �'Overnight parking Vehicle wash <br /> I, OAINIit <br /> �R�� �. 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 faits to comply with the codditions of this agreement, or if this agreement is modified or cancelled, the <br /> commiss�y owner shall notify therEHD immediately. <br /> �y <br /> Signature - err)'uGc�v �� �' - �� Date `"a <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 /> vr< ZSMgq S <br />