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C. SAN�IUAQUii� <br /> Environmental Health Department <br /> Ufet __-.COUNTY------ <br /> Greatness <br /> .-_.-.COUNTY------ <br /> Greatness grows herr <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <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 Lic.Plate# <br /> Owner/Operator Name CC�, 4 Alli -- <br /> Business Mailing AddressU <br /> CitState(, -,',r' Zip a(l S Bus. Ph. C,' Alt. Ph. <br /> I, 4 lc, Geo 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 per it holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and alties. <br /> Signature Date <br /> 01 <br /> . To be completed b CO MISSARY OWNER/OPERATOR <br /> Commissary Name // '/ FA# <br /> Address ��DG .> tCG tr,. lift ) ' ' Bus. Phone .q)o i— <br /> City - Zip V�G� wner/Operator , "�" "� .l: L tE, <br /> T <br /> Check all appropriate services provided: <br /> 16 Wastewater disposal 2 3-compartment sink ii Electrical hook-ups <br /> L! Solid waste disposal E3 Food preparation 0 Toilet and handwashing <br /> f� Hot& Coldwater for cleaning U Store refrigerated food CO Potable water <br /> 0 S e dry food/su .plies 1A Overnight parking Vehicle wash <br /> 1, /�!J+1 f 9Vfffir�lE= -- hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,an d.meets the California Health&Safety Code requirements. If the food facility <br /> operator fail � omply with the co itions of this agreem nt, or if this agreement is modified or cancelled, the <br /> commissa or shall notify th HD immeaiately. <br /> c /�'l , <br /> Signature {'7t :� �� i �tic�c-- - - ��/' Date /Q <br /> M <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uln 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 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />