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A, t, S A N J A Q U I N Environmental Health Department <br /> Er `. —COUNTY--- <br /> Greatness <br /> 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 /> 4 Business Name Gc, Lic. Plate# T=om -r? ilk <br /> Owner/Operator Name UaUd4G, /, <br /> Business Mailing Address 33 Me& <br /> City State(firy/,� <br /> Zip%dD7 Bus. Phj\Og-772146S'69 Alt. Ph. AO�d��® <br /> I,_ (!1aUd 1Ct !_= VA 7-gUP_JL , 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 iscontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation7-,',d e alties. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address �tGI®0 Bus. Phone dM•"7 <br /> City Zip S Owner/Operator A.10 <br /> Check all appropriate services provided: <br /> M Wastewater disposal M 3-compartment sink Ii Electrical hook-ups <br /> 99 Solid waste disposal 0 Food preparation N Toilet and handwashing <br /> 9( Hot & Cold water for cleaning U Store refrigerated food N Potable water <br /> 13 Atore dry fo d/supplies ® Overnight parking 12 Vehicle wash <br /> fidaA <br /> I, , 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,Aier shall notifAe EHD immediately. <br /> Signature 07t X 2. DateI 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 www.sjgov.org/ehd <br />