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SAN JOAQUIN Environmental health Department <br /> --coutvTY--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Faclity,&, Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> - — - <br /> To-berrtpieted_byAPPLICANT <br /> Business Name i 1 t75VGe1, 42r C�,TZ„IrICt tLCLic.Plate it ~L i 2)59f� <br /> Owner/Operator Name Gi00 2 CnC-. i�tJ r�lC3tz C <br /> Business Mailing AddressjaS 1 <br /> CRYO � KTp _State Zp21Bus. Ph(��9 15�5'g IL Ph.- t�!' A, _ <br /> I, ,hereby state that the above information is cument,true and carred to <br /> the best of my knowledge and agreo to utilize my approved commissary In accordance with California Health & <br /> Safety Coda, and San Joaquin County Environmental Health Department (EHD)requirements. If tine use of the <br /> commissary is discontinued,Ehg permit lder must notify the EHD. Failure to notify this of5ce may result in perm". <br /> ravocelion and penalties. rf i <br /> Signature Date L012 Z 2 <br /> �2. To be completed by.COMMISSARY OWNERIOPERATOR 1 <br /> Commissary Name f, -;,;;;,;.-. -r;t' FW: <br /> Address i > - Bus. Phone <br /> C' % �jp s p OwnerfOperator <br /> Check all appropriate services provided: <br /> U Wastewater disposal 13 3-compartment sink 12 Electrical hook-ups <br /> M Solid waste disposal 1:3 Food preparation El'Toilat and handwashing <br /> (:3 Hot& Cold water for cleaning A Store refrigerated food G Potable water <br /> 17 Store dry food/supplies 13 Ovemight parking O Vehicle wash <br /> I, 'r/;--;^. ,hereby state that the information I have provided is current,true and <br /> corroct 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 ">''. r Bate 1> <br /> 3:To be completefi by rite EIVV HfeAL fH jui7sdi'ctit5n outside`of San Joaquin Co_, <br /> The commissary is located In County, The above food facility meets the <br /> commissary requirements in Califomia 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 /> RENS Signature Date <br /> 1868 E.Hazelton Avenue I Stockton,Cal fomla 952051 T 209 468-34241 F 209 464-0138 1 www.sjgov.org/ohd <br />