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SAN J OAQ U I N Environmental Health Department <br /> -- CGU NT <br /> COMMISSARY AGREEMENT FEB 10 2020 <br /> Mobile Food Facility + Caterer ENVIRONMENTAL HEALTH <br /> Complete sections 9 and 2. if your commissary is located outside of San Joaquin County also nclomp elite section 3. <br /> 1. Tobe Completed by APPLICANT - <br /> Business Name—,t) U 0 Lic. Plate#_-31 <br /> Owner/Operator Name_ j <br /> BusinessilMlailing Address <br /> City State ,Zip Bus. Ph. Alt. Ph." �� � ✓ <br /> I, hereby state that the above information is current,true and correct to <br /> the est of my knowledge and agree t u ize 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 completedI b COMMISSARY.01N ER/OPERATOR <br /> Commissary Nam � W <br /> Addres qn Bus. Phone <br /> Cit <br /> Y Zip �(tet/ Owner/Operator <br /> Check all appropriate services provided: <br /> ., <br /> wastewater disposal 'Cr,3--compartment sink 0 Electrical hook-ups <br /> 12/Solid waste disposal 0'Food preparation ;--Pot <br /> 'To'l:Ie <br /> and handwashing <br /> 0 Hot & Cold water for cleaning 0 Store refrigerated food water <br /> � Stor dry food/suppli "and <br /> ernight parking Vehicle wash <br /> I, Rhereby state that the information I have provided is current,true and <br /> correct�to the best of my knowledge, 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 /> commiss owner shall notify the E immediately. L22Z <br /> Signature Date � 3 <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 />