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SAN J OAQ U I N Environmental Health Department <br /> - <br /> COUNTY- _ RECEIVED <br /> JUN 0 5 2019 <br /> COMMISSARY AGREEMENT ENVIRONMENTAL HEALTH <br /> Mobile Food Facility Caterer DEPARTMENT <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 <br /> Business Name F) ED jYl(&ILr iii Z,7,A 0 V Et j Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address l 112,(4 -7 -k7()G L5F j,(_ ��✓ �(�� <br /> City State 6A- Zip `1520`1 Bus_ Ph. -1t,!q- Alt. 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 pe al#i <br /> Signature /� - Date <br /> 2. To be completed <br /> `by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# 9209y � <br /> Address ( fal ���Gr'i Bus. Phone 11t_0 • qfjo.,12(a. <br /> CitZip s Owner/Operator �^`[mn�rJ�IeA1 O.N[2'tj <br /> Check all appropriate services provided- <br /> [p YVastewater disposal -compartment sink EEIectrical hook-ups <br /> olid waste disposal Z/,,Food preparation Toilet and handwashing <br /> 7�ot & Cold water for cleaning tore refrigerated food D Potable water <br /> Store dry food/supplies O Overnight parking U Vehicle wash <br /> I, jI0'y7j'4 � �1[�"" ' , 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 owner sial) noti e ediately. <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 />