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SAN:JOAQUIN Environmental Health Department <br /> '• COUNTY-- <br /> Tf greatness 9;. . RECEIVED <br /> COMMISSARY AGREEMENT FEB 10 2020 <br /> Mobile Food Facility s 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 2 t_ / ' r® Lic. Plate# /d�� <br /> Owner/Operator Name Pi/ <br /> Business Mailing Address y <br /> City State�Zip l_aa Bus. Ph.._ 2t2q f`,35A 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 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 /> revocation and penalties. <br /> Signature Date <br /> 2. To be corn leted b COMMISSARY OWNER/OPERATOR <br /> CommissaryName 4t4M <br /> Address o r Bus. Phone <br /> City Owner/Operato2 <br /> Check all appropriate services provided: <br /> 0-' astewater disposal 0--3-compartment sink 0-Electrical hook-ups <br /> p-5-olid waste disposal H Food preparation ❑Toilet and handwashing <br /> i <br /> 0-Not & Cold water for cleaning ❑ Store refrigerated food 13-Potable water <br /> ❑ Sto�e d4ee <br /> /supplies Overnight parking CY�cle wash <br /> l,�i� � herebystate that the information I have provided is current, true and <br /> correct to tf my kn wledge, 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 /> commissawn r shall IntiTy the E immediately. <br /> Signature Date 21/ ) 0 <br /> �J � <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 />