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SAN J O A 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�G ruC�� S �/{/�(/�� ��' � Lic. Plate# 356 <br /> Owner/Operator Name S f 5l c cc P, L 1�"L <br /> Business Mailing Address 15.39 C_6$$1ES`ronlf c'r <br /> City R�pc,'''I' Statee h Zip�53�,L Bus. Ph.�>°,'l `107- 7C- j q Alt. Ph. <br /> I, �E &,W ft 6 C_f)_0 S N C , 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-th-e-p rmit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pen <br /> Signature 4 Date <br /> /3��pz� <br /> 2. To be compf6ted b MMJPSARY OWNER/OPERATOR <br /> Commissary Name 'Kiri= )- U C&LqZ�-A FA# <br /> Address—Z( 7 S (( 6,1(G 6) 5-TBus. Phone J� -2- <br /> cit <br /> ZCity .5 (tc_KTt*. C c`f Zip ys C 1. Owner/Operator D L,�r—nk 0 r- �1 L -1 K fq b 0 <br /> Check all appropriate services provided: __/ <br /> VJ'Wastewater disposal Cg'3-compartment sink E Electrical hook-ups <br /> Solid waste disposal MFood preparation Toilet and handwashing <br /> Hot & Cold water for cleaning 111"Store refrigerated food L9,/Potable water <br /> CYStore` � <br /> dry food/supplies <br /> �/( Er'Overnight parking �ehicle wash <br /> I, /gql (dr ,C 6 -, 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 <br /> hall n ,4 EHD im diately. <br /> Signature �X/� Z Date 7 <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 />