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SAN JOAQUIN 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 /> 17 1 . To be com' leted.b APPLICANT I C7 F /` <br /> Business Name /1O L-' 4 R 1< ' _ /Jc. e r Lic. Plate# A(486 7.3 <br /> Owner/Operator Name /Yli �taC'JL rya h� er oo Y <br /> Business Mailing Address <br /> CityG,rshIState�Ziip 89/06 Bus. Ph.6 0-( 6L j l5 5 It. Ph. <br /> I, l✓1 rel, ae L /eyiAe 1-�, oat , 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. D <br /> Signature Date f5 --%0 <br /> 2. To be cam leted b COMMISSAR' "OWNEFWOPERATOR <br /> Commissary Name �Ce �'a_F�AL # <br /> Address f t(3!� &Z WtBEk �IE Bus. Phoney 2-0 <br /> City cSTUC,IC B�&j_Zip9S til— Owner/Operator ��- <br /> Check all appropriate services provided: <br /> ❑ Wastewater disposal 0'3-compartment sink ❑ ,E rectrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food ❑'Potable water <br /> ❑ Store dry food/supplies ❑.overnight parking [Vehicle wash <br /> I, L/tr,�r4 A G{f-eJUINA U)67k , 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 /> shall notify the EHD im iately. <br /> Signature � �`-- — r Date 2_020 <br /> 3. To be com leted by the- -E N V HEALTH 'urisdiction 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 />