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SAN t UA Q U I N <br /> Environmental Health Department <br /> r , <br /> i'n' .�'P ` ° COUNTY <br /> c9•JFa�=`' Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility *, Caterer <br /> Complete sections 7 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 IWCG, �� { Eic. Plate# <br /> OwnerlOperator Name o 1" ,. <br /> Business Mailing Address I Ci <br /> CityState AZipT40,� Bus. Ph._ 1�� It. Ph b S� �j 00 <br /> I. hereby state that the above information is current,true and correct to <br /> the best my k owl��e 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 Z�,��' �tJl^ , Date <br /> 2, To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Nama_cnm �� j :KLM C- FA# <br /> Address - y0'C 6- =- —__Sus. Phone 70 - <br /> CitZip Owner/Operator �f E}C� <br /> Check all appropriate services provided; <br /> ,["Wastewater disposal LZf__3-compartment sink �Electrical hook-ups <br /> Solid waste disposal ffl—Food preparation i0-Toilet and handwashing <br /> lel Hot & Coldwater for cleaning t wtore refrigerated food table water <br /> LlwStare dry foodlsupplies Overnight parkinge'hicle wash <br /> I, Z , hereby state that the information I have provided is current,true and <br /> correct to tfie 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, the <br /> commissary owner shall not fy the EMD immedia#ely. <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 /> RENS 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 />