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SAN _J0A0UIN Environmental Healt9bWWWt <br /> �.° COU NTY-- <br /> __ r; Greotness grows here. JUL 10 2019 <br /> ENVIRONINIE'VI-AL 1-IE:ILTH <br /> COMMISSARY AGREEMENT 1)E'PARri1IEN-F <br /> Mobile Food Facility e 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 Ckcus Lic. Plate#/-,j 4_/f4lori; <br /> Owner/Operator Name C';\C\\O)r SCN C-\,c cLY1 C� <br /> Business Mailing Address \Zi5 C\ <br /> City State CXZipC\533_k Bus. Ph. <br /> I. C"1(.\\:>`C Ck\Cn-,GC _�cn C.\, 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 �L/7✓��� _ Go lre"- "l /f e-1-7,q" Date C�`�-I 1 O 1 I C, <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 6 1� `%�'vrn�L ����P�th� ;��J(� FA# <br /> Address Al i- z c WU&4 Bus. Phone���y <br /> City S c.((JCi �Zip S20 er Owner/ r S 7�kit <br /> Check all appropriate services provided: <br /> Wastewater disposal G-5-compartment sink electrical hook-ups <br /> olid waste disposal Le Food preparation Toilet and handwashing <br /> t & Cold water for cleaning 'Store refrigerated food Potable water <br /> Store dry food/supplies Q'Overnight parking dVehicle wash <br /> `71�'&') , hereby state that the information I have provided is current, true and <br /> correct to e 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 shall notify the EHD immediately. <br /> Signature —` " Date 1 C/ <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 wwvw.sjgov.org'ehd <br />