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GUIhJ'' <br /> °r c° S A N J 0 AQ U I N Environmental Health Department <br /> --COUNTY <br /> Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3- <br /> 1. To be completed by APPLICANT ,y <br /> Business Name ` A C b Lk" o t"Q Lic. Plate# U%-] (0 u 13 <br /> Owner/Operator Name 7_5 r I <br /> (6( r� a hn ir� <br /> Business Mailing Address 4+/1— A �1� S-tri � <br /> Ci: (�`I <br /> State_2Zipq�Bus. Ph. � - 190' 92+9 <br /> 2+9S It. Ph. <br /> 1 , 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 Cou y Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,the p it holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation an penalties. 1 f <br /> Signatur Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary NameF/A# <br /> Address 67C1 S' `�b�r�rc,��fi� �S Bus. Phone l� l��l � 2-2-1 9 555/ <br /> City Le 0 l Zip q 5 2-fe/ Owner/Operator_ <br /> Check all appropriate services provided: <br /> [a-VVastewater disposal compartment sink Electrical hook-ups <br /> m,-Solid waste disposal ®Food preparationilet and handwashing <br /> of & Cold water for cleaning Store refrigerated food CJ/�_otable water <br /> tore dry food/supplies Overnight parking W6ehicle wash <br /> I, kZ �-ce' , 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 Date l l� <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 /> Pat osy ��g� <br />