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r SAN:JOAQUIN EfiHvG ronmenta� Heaeth Depar£ment <br />—COUNTY— <br />r` Greotness yror:s here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility s Caterer <br />Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT f <br />Business Name l.{ }lei Q I `�i�CJC/ 1�� Lic. Plate #'d ED 3 tq <br />Owner/Operator <br />Business Mailing <br />City Vhfi <br />1, T.r <br />- AY 1 (`1WVW(' )-, 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 di continued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and rAlges. <br />Signature—U ri i U \ <br />12. To be coMpleted by COMMISSARY OWNER/OPERATOR I <br />Commissary Name ri7"Grvrwt. Sir/ FA# <br />Address 6772 S SG6rewr4/ _5+ Bus. Phone ! !Ze9) 22Y 83351 <br />City LGrje Zip 'IiZ9G Owner/Operator AIr, a �- <br />Check all appropriate services provided <br />0*�Nastewater disposal ��compartment sink LE "Electrical hook-ups <br />®olid waste disposal PFood preparation Fp- Toilet and handwashing <br />iA Hot & Cold water for cleaning k Store refrigerated food a`Potable water <br />KI-I§iore dry food/supplies IA Overnight parking EJ�Vehicle wash <br />I, /r7 f-PLo, 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_ a6rt_-�= Date 7- /i1/ -Z.2 <br />3. To be completed 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. <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />