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SANdOAQUIN Environmental Health Department <br /> 2 ,_�`_ Z, <br /> N 1Akc41 - COUNTY <br /> f'q Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility r 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 /> 1I ` <br /> Business NamIs 1 S -Th( (� Lic. Plate# <br /> Owner/Operator Name j(r,(� L.Ac tv \. <br /> Business Mailin Address b t� <br /> City te_ Zip "1 S2� Bus. Ph. Alt. PhIM <br /> I, PUAJ �)� P. !—rt 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 pen ties. <br /> Signatur Date <br /> J. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 11h �A# <br /> 1 � <br /> Address J� (� 0 Bus. Phone2 <br /> City L Zip Owner/Operator a. �S <br /> Check all appropriate services provided: <br /> �� <br /> [.wastewater disposal C33-compartment sink fl Electrical hook-ups <br /> p !�olid waste disposal ® Food preparation 131<oilet and handwashing <br /> Er'H'ot & Cold water for cleaning tore refrigerated food C215otable water <br /> 112-1�tore dry food/supplies 4-2-0vernight parking t3 vehicle wash <br /> I, , 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 con itions of this a reement, or if this agreement is modified or cancelled, the <br /> commissaowne shall n ify the E immediately. 1 <br /> Signature Date I <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 />