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Date DE c, 202$ <br />commissary ••,/ 7r :hall notify HD immediately. <br />Signature <br />Date <br />Bus. Phone <br />FA# <br />go9- oI WIz <br />To be completed by APPLICANT <br />Business Name E Gr u I 1 (-) Lic. Plate # 21' <br />Owner/Operator Name 19- / /7 C ; a 66,Fifir.:)fp <br />Business Mailin9 Address ?'/ 77 Oa var,-Sc 0 c C 6 <br />City c iv, k State 04 Zip 7q1/ 2_Bus. Ph. *9 1( 62 -p/26It. Ph. <br />, 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 pen <br />Signature <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Et #-,3 <br />Address ,225/ E <br />cityccih_c,„, zip QS-2_ CS" Owner/Operator <br />Check all appropriate services provided: <br />Wastewater disposal 0 3-compartment sink <br />13 Solid waste disposal 0 Food preparation <br />Hot & Cold water for cleaning 0 Store refrigerated food <br />Store dry food/supplies Eit Overnight parking <br />I, adCk oeyruo , 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 />Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br /> SAN:JOAQUIN <br />, <br />Sttold <br />Environmental Health Department <br />—COUNTY— <br />Greatness grows her , <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 />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. PIP0-sepptify END if he status of their operating permit changes. <br />REHS Signature . „ Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />HZ0s3SigLa