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SAN JOAQUIN Environmental Health Department <br /> th t� 4 '- --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 APP,`LICANT <br /> Business Name it V� p Q l ` 0p � IE D 0 N P d L(Wic. Plate#n �n ^� � ,�Sn 2� <br /> Owner/Operator Name, ! 1 L �T �� �C) C�� I � � !�—U! V -,, r`V <br /> Business Mailing Address -7 S <br /> City tt�C State ChZip 15� l(PBus. Ph. W6) <br /> I, J , 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 penaltie r Z <br /> Signature Date U f I 1 I-Zbl`o <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name l �Q CK l(AjF NrE <br /> Address N (ON Bus. Phone 2nG1 1 19 - S <br /> City 5TD1(��n/ Zip Z Owner/Operator ��� T 9AP6 <br /> Check all appropriate services provided-. �Cj E C"1 HT- <br /> Wastewater disposal 3-compartment sink J1 Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food Potable water <br /> Store dry food/supplies Overnight parking Vehicle wash <br /> 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 fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owyshalt" e . tely.t vy Zl 207Signature Date3. To be cd b 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 Califomia 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 /> ' C<"Z c N 2 <br />