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SAN JOAQUIN Environmental Health Department <br /> ----COUNTY— <br /> Greatness qrc.., h=re <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 cLely d s d L i Dr(l T S Lic.Plate# 4�RV L,z 2-3 <br /> Owner/OperatorName ,�fi iy 7 h1cLL�/Cf` DEiN (�RJZ� 53 0///iiL'IE A�IGi/iyti'C <br /> Business Mailing Address 9502- FOO ( 'X EfK A2 <br /> City.STU'-" StateLfi Zip ` 2! D Bus. Pt(2cO95S 7l/I Alt. Ph. <br /> I, S��Qo(j{N'�(e OQ k L' n( I ,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 h124I2021 <br /> 2. To be com leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 6Wr`V 1UI L/t T—(?(2(G (�t(4_k C E(C - rl- FA## <br /> Address l 7 / 7 S. u(J(0fk� ST Bus. Phond�;?cS) Zy SJ' - S <br /> City0/iS6c k c t7, C(} Zip CC- Owner/Operator fTwQiT (( !1 d G <br /> Check all appropriate services provided: <br /> a-Wastewater disposal T-37compartment sink ffElectrical hook-ups <br /> Ef'Solid waste disposal Food preparation 1: Toilet and handwashing <br /> M�Hot& Cold water for cleaning ::St re refrigerated food ElfPotable water <br /> store dry food/supplies t Overnight parking Ctif Vehicle wash <br /> 1, /]`/�1 Z �Rd G hereby state that the information I have provided is current,true and <br /> correct to the 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 noti the HD immediately. <br /> DateSignature (2c <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 />