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S A N 10A Q U I N 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 /> Business Name s f C r� �..iP��M Lic. Plate# 2 ` _S <br /> Owner/Operator Name lui.7�E E`r 4 H <br /> Business Mailing Address 27IS._ H kL r3�(_T_�_ c <br /> City_ 611J StateC. <br /> aZip Bus. Ph. 2—c 9-ZfZc )3 1t. Ph. <br /> I, /-Y7e,11 v'_tr <f0 A hereby state that the above information is current, true and correct to <br /> 19 <br /> the best of rffy 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. <br /> Signature M,'.,qf-0r p Date ,2-14 • 26 ;�_O <br /> 2. To be <br /> completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name �' f CI���/' ci r, ��� c•� aryl <br /> FA# Cn w <br /> Address 34 fSk E^ mj Bf ER A V67 Bus. Phone 9 A <br /> Zi ci Q S�. a S Owner O erator . Z <br /> City S'i� CK 7-"�-,r p 1 p fl'I G) <br /> Check all appropriate services provided: Z is O <br /> p Wastewater disposal 13 3-compartment sink Electrical hook-ups Z n <br /> comm <br /> p Solid waste disposal M Food preparation N13 Toilet and handwashing <br /> O Hot & Cold water for cleaning Store refrigerated food Potable water < ;0 <br /> 0 Store dry food/supplies Nn Overnight parking E3 Vehicle wash In > <br /> sc <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 owner shall notify the EHD immediately. <br /> Signatures,., 6 ,rn..',x Date <br /> 3. To be <br /> 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />