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• <br />SAN JOAQUIN golie COUNTY <br />,..4111Sto'ir <br />• Gr,:otness qt0A5 <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 />To be completed by APPLICANT <br />Business Name Stti-ii.c. 1 0.( os- Lic. Plate # 4-4C k/1 1 13 3 <br />Owner/Operator Name 3e rcji <br />Business Mailing Address (Di g Cve c.+- <br />City Stc/C-4.fzi State C-4 Zip ci-C2-47 Bus. Ph. Z-041-Li ,K197 Alt. Ph. <br />I, Serccp c r- 4-1 , 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 County Environmental Health Department (END) 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 Date <br />To be completed by COMMISSARY OWNER/OPERATOR <br />VY) 'IV) 1 SC\11.) -V 1 u FA# Commissary Name <br />Address 355 c- fl\i-e._ Bus. Phone C2-()C- S,'3q - ZS / <br />City I. 0(k:k Zip 9 52,1 Owner/Operator <br />Check all appropriate services provided: <br />(Wastewater disposal 12 -S-compartment sink -CrElectrical hook-ups <br />?<-Solid waste disposal 7 Food preparation )3-Toilet and handwashing <br />& Cold water for cleaning Store refrigerated food j:1--Potable water <br />7: Store dry food/supplies ri-Overnight parking a-Vehicle wash <br />I, C,U1rCickk: L',rAk/er-L._ , 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 no fy the EHD immediat ly. <br />Signature <br /> <br />Date <br /> <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 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />VOD0/2_010