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SAN.JOAQUIN Environmental Health Department <br /> yi <br /> r `;%! ` —COUNTY— <br /> ``.9ee?P' Greatness grows her-:. <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 r 11 I &A G. Lic. Plate# uA-�jf 13 <br /> Owner/Operator Name ao Business Mailing Address e,244- Mn, to 2 &F <br /> City State�Zip q;5,3UBus. Ph._ ej —G��_"it lt. Ph. <br /> I, / fG�tf7 hereby state that the above information is current, true and correct to <br /> the est o 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��4 Date Q Gj j.- <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryNameFA# <br /> Address V Bus. Phone l7C' Z`/ ` 5 <br /> City L 121 Zip q5_1- /D Owner/Operator �l yir,✓+�' hGvre <br /> Check all appropriate services provided:l <br /> Ul/Wastewater disposal Q4compartment sink a Electrical hook-ups <br /> P/Solid waste disposal Food preparation EY Toilet and handwashing <br /> �Iot & Cold water for cleaning �5tore refrigerated food 0'Potable water <br /> 0/Store d food/supplies lies _ / <br /> dry pp rYOvernight parking f'P�C/ehicle wash <br /> I, ,a, G,c'o A zt {a;r , 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 shall notify the EHD immediately. <br /> Signature� (s. . — Date r/ ' 1 Z I <br /> 3 To be com feted by the ENV HEALTH jurisdiction outside of San Joa uin 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 />