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,= S A N J O A Q U I N Environmental Health Department <br /> US 196 COUNTY RECEIVED <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT MAY 2 8 202; <br /> Mobile Food Facility 4, Caterer ]'NV]140NNIF'N�iALIILALI'lI <br /> lEIPryRT•1EN`1' <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 1'r Lic. Plate# A t <br /> Owner/Operator Name_ <br /> Business Mailing Address. 193 S - <br /> Cityf State Ca.Zp 92DG Bus. Ph. 7dq'_ qu/-(��It. Ph. <br /> I, 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 .�. Itie <br /> Signature Date S-Z7- ZO zl <br /> 2. To be completed by COMMISSARY O. -W- NERIOPERATOR <br /> Commissary Name- ro doc11 la-Zc FA# 00Z��-�9�, <br /> Address Bus. Pho -Z-o6i <br /> City a ru Zip ��3�7 C7 Owner/Operator J L <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink 117 Electrical hook-ups <br /> )� Solid waste disposal 13 Food preparation Toilet and handwashing <br /> 0 Hot & Cold water for cleaning 0 Store refrigerated food ."Potable water <br /> 0 S e d food/supplies supplies �Overnight parking , Vehicle wash <br /> I, LmS , 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 omply with th o tlitions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary er shall n he HD immed' y. <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 /> PP 2(P 2 211 <br />