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SAN -J O A Q U I N Environmental Health Department <br /> '�.i —_COUNTY <br /> ac r.ca`' Greatness grows here. <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 O�) 51) 0(4 L' Lic. Plate# <br /> Owner/Operator Name C 1 C A V �t�k)C© (, H A Z ft1 Il: I <br /> Business Mailing Address 2 2 0 0 1 0 C,1 L C' h1 U <br /> City C-)'(0CK-T0,-Q State_CA Zip C1 S,3®(i Bus. Ph. �Ccl -,-5qO`,;q&:jAlt. Ph. <br /> CM4ZA g1,jj , 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. /� <br /> Signature At,"``f c IFPCDate /=3Q/,;?0,;?,3 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName k),UO CTlf I& 1 OU, , CeMESA# i <br /> Address 1111 �)• j) QJ, 5'1 Bus. Phone (Zi)w) 2-9k— JSP! <br /> City 2M('K16r3 Zip CJS -�C' (4�1 Owner/Operator Al 7" -7/6a 0 Pi <br /> Check all appropriate services provided: <br /> p Wastewater disposal E3 3-compartment sink O Electrical hook-ups <br /> p Solid waste disposal ® Food preparation ® Toilet and handwashing <br /> E3 Hot & Cold water for cleaning 0 Store refrigerated food ® Potable water <br /> G Store dry food/supplies [3 Overnight parking 0 Vehicle wash <br /> I, �r�( I CA 00 , 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 owners all " tify the EHD immediately. <br /> Signature Date <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 www.sjgov.org/ehd <br />