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• <br />SANdOAQUIN <br />----COUNTY-- . aSzejr 'Tc ogt.'" Greotnes C' t !c <br />Environmental Health Department <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 ,--e,,ye(:) OZ Lic. Plate # vc) <br /> <br />Owner/Operator Name 4F-Cbe ( ,ety/e3- <br />Business Maili g Address q 2& ,ktG, /017/ <br />City C 9I StateC4 Zip qS---2-/Bus. Ph.2,e) j6; 5 -1.,17' Alt. PhiO <br />CIPI`e 1 k7'e , hereby state that the above information is current, true and correct to <br />thebest of my knowledge' nd 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 />revocatiopylties. // <br />Signaturrae <br />( <br /> <br />- 23 <br /> <br />Date <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name ,zr-//-7/ c("qi fr t FA# <br />Address :Zr c-2 ///' Bus. Phone _2-99 Zi?1,71 <br />/ <br />City Zip Owner/Operator (/,.;),i, /4) <br />„../ <br />6/) <br />Check all appropriate services provided: <br />iq- Wastewater disposal p) 3-compartment sink 11'3:Electrical hook-ups <br />Er Solid waste disposal 13 Food preparation EXToilet and handwashing <br />9/Hot & Cold water for cleaning 0 Store refrigerated food pi-Potable water <br />0 Store dry food/supplies Overnight parking 4-- Vehicle wash <br />I, /4/2.2 ..e 7-74) , 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 n tify the, EHD im c,fiately. <br />Signature .:,:-.:___;4..,,,( z";:----;10,-._,:-17 -- Date <br />7) <br />To be completed by the ENV/ LTH 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 T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd