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- - -- SAN-JOAQUINEnvironment <br /> a°lth�Department <br /> —.COUNTY-- <br /> Greatness <br /> •COUNTYGreatness groves 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 'i <br /> A. Piate#�L7 ) LIS Z <br /> Owner/Operator Name G 4 <br /> Business Mailing Address 2 L)7,5_ L' A419j A <br /> City STO C(<7(; 0 State_aZilf�Bus. Ph.20` )-UA-[:PI '7(Alt. Ph. - i <br /> 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, e permoolder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties ) <br /> Signature _ ? i r Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name J)Aji 6,0 C A jbjZ_1 /U(;7 [f(,ICK :L&,Tt:9 FA# <br /> Address 111 �_' OAA 6.0 5-7 Bus. Phone_261 - 2 k - 5 <br /> cityZip L—.'—Owner/Operator A)'S*ff eA/ -- 1 zzAa <br /> Check all appropriate services provided: <br /> PfWastewater disposal A 3-compartment sink 'tie, Electrical hook-ups <br /> J55 Solid waste disposal 'Food preparation Toilet and handwashing <br /> AS Hot&Cold water for cleaning *Store refrigerated food � Potable water <br /> Store dry food/supplies �Ovemight parking !Vehic':W:h <br /> hereby state thatthe information Ie proviedcurrent,true and <br /> corr 'ct 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 shalLootify the diately. <br /> Signature Date 2 01 c./ <br /> 3. 10 be completed by the ENV WEALTH 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 Avenub 1 Stockton, California 95205 1 7 209 468-3420 1 r 209 464-0138 1 www.sigov.org/ehd <br />