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SAN J A U I N Environmental Health Department <br /> COU N T.f...._.._ <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 ��r ��sJ� r�S (/i� i Lic. Plate# <br /> Owner/Operator Name S&L GWDR P,'_Rff 7- <br /> Business <br /> Business Mailing Address <br /> Cityc52C6/>/ Stateell Zip 9S2©6 Bus. Ph. 2_Z7- 'k6776 Alt. Ph. <br /> I, SAL —, 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 <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name a l l O ej C R c A�41 6 ­rp-U6 ilt 4 66 6X FA# <br /> Address / 7 f 7 6, u V(b (0 5 ( Bus. Phopp�►ne 61) �3 g Sq)� <br /> City I K C 4 zip ?,f2 C�- Owner/Operator h� ( I ✓�aij 6 <br /> Check all appropriate services provided: <br /> ED/Wastewater disposal 1/3-compartment sink 01/"Electrical hook-ups <br /> [/Solid waste disposal EI'Food preparation L'Toilet and handwashing <br /> M"Hot & Cold water for cleaning D/Store refrigerated food Potable water <br /> L7'Stto7re dry_food/supplies <br /> � Overnight parking Vehicle wash <br /> l <br /> I X r`Q� 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 ow r s a 11 diately. <br /> I 7 <br /> Signature — Date 6�2_Z--4' O Z <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 />