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SAN J O A Q I N Environmental Health Department <br /> _-_ <br /> COUNTY-_--_- <br /> Greatne: Pere, <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 <br /> GAPPLICANT <br /> Business Name -rpCos `r '%ve-itTo S ���i d� Lic. Plate# <br /> Owner/Operator Name SRZ d'f dDk /SER,EZ <br /> Business Mailing Address /b Cx�MbE 5T- <br /> Cit <br /> T <br /> CitycSaC� /) n StateeIIj Zip 9S2©6 Bus. Ph.�8�� 7r 7U Alt. Ph. <br /> I, 5h L U1j D,A f"r_?E z 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. /2-Signature — Date "//�z L Z`' <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Ll 6� C h C tlk 1 6 r p-U6� C�����' FA# <br /> Address 17 t 7 S, rO ( Bus. Phone 6`(� .2, $ 1 <br /> City _�3-IT C���. C Zip Owner/Operator ( I ou <br /> Check all appropriate services provided: <br /> Wastewater disposal 0/3-compartment sink Electrical hook-ups <br /> 'Solid waste disposal Food preparation [Toilet and handwashing <br /> M"Hot & Cold water for cleaningU'Store refrigerated food El"'Potable water <br /> 'Store dry food/supplies AG Overnight parking 1"Vehicle wash <br /> Wl`4 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 s a lim diately. <br /> Signature Date �� <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />