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SAN JOAQUIN Environmental Health Department <br /> COUNTY - _ <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/b APPLICANT <br /> Business Name MO-yJ10 2 1 C60 CY&G.Z29 Lic. Plate# _ 91 63JI <br /> Owner/Operator Name /.[ r,'n /G OS4g7i <br /> Business Mailing Address q 3Z( L lun,��c. S J� <br /> f yld `O <br /> City M,o.,e fecA,1� �State�Zip gE,7?e Bus. Ph.�o`]) 5 �r-13��Alt. Ph. <br /> I, l.Yt G i"tG� h , 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 /`le a l ' /Jsc�7�&C Date!✓ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name P i C 1c n/ G o FA# <br /> Address 3u ni ;Al - Q Bus. Phone <br /> City Sia CK i ory Zip gsgos- Ow er/Operator ow,n/� O 0) <br /> Check all appropriate services provided: O <br /> 0 ^� _ <br /> 0 Wastewater disposal O 3-compartment sink '�-M Electrical hook-ups m . <br /> 0 Solid waste disposal \ O Food preparation Toilet and handwashing Z C <br /> O Hot & Cold water for cleaning �L9 Store refrigerated food 0 Potable water Z f <br /> rl <br /> 0 Store dry food/supplies �I� Overnight parking 0 Vehicle wash D X <br /> to <br /> I, hereby state that the information I have provided is current, true and 0 D � <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility N M rr <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the D <br /> commissary owner shall notify the EHD immediately. 3 <br /> Signature 1.rfr,-, �-e' a (-�' Date // -5,- <br /> 3. <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 />