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, <br /> SANAAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grcw.s 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 q <br /> Business Name Lic. Plate# <br /> Owner/Operator Name "0_4 0601 ,rA& M01GN61M <br /> Business Mailing Address L03 &JORM X10R1 A16S Gl R <br /> CitySTbCkfQ)4 State e-t9 Zip 95210 Bus. Ph.C207) 351 '.Z7?Z Alt. Ph. <br /> I,�d i P9 u j- Vl7R(„au , 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. <br /> Signature Date 3�/;//'a <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR A, <br /> Commissary NameU/lSlo Glf���(C/RlG l d[�25 FA# <br /> Address�7/' S. 6!/f 4,1/ S f Bus. Phone,/2r-"t) J_ F <br /> City ST ekTDri r C X Zip '?:Z06 Owner/Operator_IfR7- //21; 'o <br /> Check all appropriate services provided: <br /> Wastewater disposal @'3-compartment sink It Electrical hook-ups <br /> M-Solid waste disposal [3 Food preparation MToilet and handwashing <br /> 133"Hot& Cold water for cleaning MlStore refrigerated food la'Potable water <br /> dStore dry food/supplies ❑O ernight parking C"Vehicle wash <br /> I'_7,n / l 1 gfiaO , 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 shalt notify the EHD immediately. pp� <br /> Signature `� Date <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 />