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2,t SQNJQQQUIN Environmental Health Department <br /> �r 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 APPLICANT <br /> Business Name -X41 C4--�Z-r ��J�, Lic. Plate# Z S <br /> Owner/Operator Name <br /> Business Mailing Address <br /> CitStateZipciBus. Ph.2.00�,'" 14 " h. <br /> I, (�1s3 "��1/1Q� , 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 penalties. 1 <br /> Signature/. Date L� 1 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> r <br /> Commissary Name 0 t06S f25t�lc,J �8,n c) // FA# <br /> Address 20 � '�,2 i4 �"�' . Bus. Phor4e_��(� <br /> CitZipq S d- 7 Owner/Operator t nl r 9-X "% (;3<n1^7 <br /> Check all appropriate services provided: <br /> p Wastewater disposal C3 3-compartment sink O Electrical hook-ups <br /> [Solid waste disposal Food preparation 0 Toilet and handwashing <br /> eHot & Cold water for cleaning 0-,tore refrigerated food 0 Potable water <br /> 0 Store dry food/supplies E3 Overnight parking 13 Vehicle wash <br /> I �a /ag-j o t.j ,- LK 4LJ , 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 conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ow all no ' e EHD immediately. I 2 , <br /> Signature Date <br /> 3. To be com I d by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary ' 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 />