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• ;pU1N `Ll� Sf' UDAQVI� <br /> "-�� Environmental Health Department <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 /> t_ �� } F <br /> Business Name G� ' `��1�� Lic. Plate# �l�AL4# -) £� <br /> Owner/Operator Name -S7AAj 6/ � 4C" -f S! <br /> Business Mailing Address SGLi1���1��G'Z wI do <br /> city '�z:� r6 State_CAZip TS,2,6Bus. Ph�<_- S'�rj' Alt. Ph. <br /> 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 penalti s. <br /> Signature 1 Date C� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name !t�t4l(CL « « N FA# <br /> Address /4f36— /WC/10—r- Bus. Phone <br /> City� . t�6+� Zip 9 5ZQ S Owner/Operator ��G`` ���►''�u'�� <br /> Che all appropriate services provide <br /> Wastewater disposal ❑ 3-compartment sink 113­15lectrical hook-ups <br /> ❑ S I.id waste disposal ❑F oQd preparation ��oilet and handwashinZg <br /> Hot & Cold water for cleaning Store refrigerated food Potable water <br /> n Store dry food/supplies ❑,,_�Iernight parking ❑ Vehicle wash <br /> I, QE_�N R C.N-uM Lo E-Q , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and eets 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 /> "(�Z ryl w ^ s� Date U� �v <br /> Signature `��C�j�_ weA- <br /> 3. To be completed by the ENVHEALTHjurisdiction outside of San Joaquin Co. <br /> The commissary is located in � a h v,a County. The above food facility meets the <br /> commissary requirements ' California Health & Oety Code. The above checked services are available at the <br /> above commissary. PI se notify EHD if the status of their operating permit changes. I <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 />