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SAN 10A Q U I N Environmental Health Department <br /> COUNT-Y - - RECE <br /> i <br /> COMMISSARY AGREEMENT FEB 13 2020 <br /> Mobile Food Facility f Caterer ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <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 s/�"?a E�-i11'e <br /> Lic. Plate# <br /> Owner/Operator Name Cc 'e <br /> Business Mailing Address Uir)S. f- <br /> City � State 64-zip l ' G61Bus. Ph.-7trr. l of Alt. Ph. <br /> I, 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 holdmust notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe al esy <br /> Signature «LC, Date-. <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Co mi sary Name ,`e-9rf./C FA# 00 0 V—,� <br /> e <br /> Address <<?e IL ';? Bus. Phone <br /> City ' C /�C' '� Zip Owner/Operator <br /> Check all appropriate services provided: <br /> ❑ Wastewater disposal 0 3-compartment sink Electrical -u s <br /> ❑ Solid waste disposal [3 Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning p Store refrigerated food ❑ Potable water <br /> 1 Store dry food/supplies Overnight parking ❑ Vehicle wash <br /> I, fl }' /r i 1 -�! 1 ,;--/A -/` 6reby 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 er shall notify th EHD immediately. �r <br /> Signature- Date f <br /> 3. To be 6ompleted 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 />