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SANAUN <br /> Environmental Health Department <br /> • 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 J <br /> Business Name _TOr1`11161_� 1_Ct [1trC64r(Tr Lic. Plate# I W Q 42)9-9 <br /> Owner/Operator Name A�n, re,-) <br /> Business Mailint W Q 0 <br /> g Address (a �. ee I0 <br /> � ��. <br /> City � 6 -`b n State Zip q�OS'Bus. Ph."094 Alt. Ph(S[01):+l L— 3S14 <br /> I. >e, 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 enalties. <br /> Signature Date <br /> z - <br /> 2. To be Completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name (6jj&A#U <br /> Addresssi I] I ) g • (1111 G YN � Bus. Phone - SZ` <br /> � <br /> City � QCIO A-) Zip 05�aC_ Owner/Operator ot) % <br /> Check all appropriate services provided: <br /> ;3 Wastewater disposal 073-compartment sink Electrical hook-ups <br /> P+ Solid waste disposal E3 Food preparation Toilet and handwashing <br /> Pill,� Hot & Cold water for cleaning E3 Store refrigerated food /JQ Potable water <br /> E3*to <br /> food/suppli [] Overnight parking M Vehicle wash <br /> I, hereby state that the information I have provided is current, true and <br /> coest of m e,a d meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comp) with the c ditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall n 'fy immediately. r <br /> Signature Date 'a L�� <br /> [ 3. T om leted 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />