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SAN 10A U (N <br /> Q Environmental Health Department <br /> tiYr' Y ____COUNTY---- <br /> e C't %S 5 4 <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 /> 1: To be completed by APPLICANT <br /> Business Name WL 'r i Lic. Plate# <br /> Owner/Operator Name rre <br /> Business Mailing Address <br /> l <br /> City �� State Zip ��Bus. Ph20 L Z Alt. Ph. <br /> I, 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 pen (ties. Q n <br /> Signature Date V w <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Ot 6nb- 11 0 YoC" A# <br /> Addre s t`o � Bus. Phone ✓ J �/ �r� <br /> City Zip Owner/Operato S <br /> Check all appropriate services provid_ed- <br /> /Vastewater disposal ❑ 3-compartment sink CYElectrical hook-ups <br /> [}-'Solid waste disposal E3 Food preparation C� T"�oilet and handwashing <br /> ;--O�Ota Cold water for cleaning tt <br /> tore refrigerated food "Notable water <br /> tore dry food/s plies G-(�vernight parking 0 Vehicle wash <br /> I, UAQW& hereby state that the information I have provided is current, true and <br /> correct to the best o y 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 o er shall notify the EH mediately. <br /> Signature � _ � /�✓� Date <br /> ' 3.'TO be completed by the ENV HEALTH jurisdiction outside of San Joa. uin 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />