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SAN 10 AQ U I N Environmental Health Department <br />--COUNTY—-- <br />COMMISSARY AGREEMENT <br />Mobile Food Facility + Caterer . <br />Complete sections 9 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 <br />Owner/Of <br />Plate # I <br />Business Mailing Address /(OW J. <br />CityS^-106,641,' @ State�Zip�Bus. Ph.61--717,719a* Alt. Ph. <br />I, 114M tJ1 &j'iL'--) 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. J Q �p <br />Signature /NLa ' %//' -7.�✓ f Date '44'�r� <br />2. To be completed/',, by rCOMMISSARY /OJWN®ER/OP/E�RATOR <br />Commissary NamecOC(%Ckt �/�7 S �6Y1Qt2l`f `tip �CG (�"FA# <br />Address !y 3n- E WEREA Ay'c Bus. Phone <br />City SZ`lU7JN ZipOwner/Operator 2e"t GltyLrtjQ,4 <br />Check all appropriate services provided:: <br />Wastewater disposal C"3 -compartment sink I0_�Electrical hook-ups <br />1ySolid waste disposal Ci Food preparation L i I oilet and handwashing <br />M Hot & Cold water for cleaning 117/'S�tore refrigerated food C'Potable water <br />C3 SJtore dry food/supplies .Overnight parking 0 Vehicle wash <br />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 sh notify the EHD immediatfily. k <br />Signature (y�f'ivt�en L " yv� Date &A/ys /ZoZ 1 <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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wwev.sjgov.org/ehd <br />