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SAN JQAQUIN Environmental Health Department <br /> —COU NTY— <br /> Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility♦ Caterer <br /> Complete sections ?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 �FrArl Cl SCO 0dje aOt Lic.Plate# 'L4 U 6 y 5LI Z <br /> Owner/Operator Name frAr1CIS CO j204SkA C()en1 <br /> Business Mailing Address loot S• r D lel e n ()wk Ai,^P, <br /> City__§ � 0✓t State Ch Zip �IS�S Bus. Ph. 14q • (119 •q25 AIt. Ph._ 2(�� • yJS g 3 I� <br /> I,fyAnCI SCO 10IIMC 1 hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree Yo 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)( e(� P ✓Y Date 22 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name jjNIGk eil-MQi6i ARUCK CENT&,PFA# <br /> Address (7 ( 7 5, ud(otJ sT Bus. Phone �o96�Zt?T-S1f4 <br /> city,6 a- e_ �C� Zip9,�_,z o 6 Owner/Operator �f R� I 1 KW D <br /> Check all appropriate services provided:: <br /> Wastewater disposal : compartment sink M/Electrical hook-ups <br /> SCA <br /> olid waste disposal pFood preparation "Toilet and handwashing <br /> �Vof&Cold water for cleaning e//Store refrigerated food �otable water <br /> tore dry food/supplies M'Overnight parking 12,1%ehicle wash <br /> I, 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 ow =HDimmediately. <br /> Signature Date lr�oi�2 a z z <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 wvvw.sjgov.org/ehd <br />