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SAN J O A Q U I N Environmental Health Department <br /> .Ix1k� --COUNTY--- . <br /> Greatness grows herb. <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 /> r <br /> Business Name Lic. Plate# <br /> Owner/Operator Name <br /> Business Ma"ing Address Q oZ <br /> City Stated# Zip Bus. Ph. b - b, -'?)?"7T Alt. Phjt/-31, 2pt'� <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 iscontinued, the p holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a penaltie . <br /> Signature Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address oC d Com'. Bus. Phone <br /> City Zip 95 O Owner/Operator <br /> Check all appropriate services provided: <br /> IS Wastewater disposal 3-compartment sink Z Electrical hook-ups <br /> JZ Solid waste disposal it—_j Food preparation S- Toilet and handwashing <br /> 59 Hot& Cold water for cleaning 0 Store refrigerated food P9 Potable water <br /> Sire dry fo upplies I Overnight parking Vehicle wash <br /> I, /wJ /� E �� 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 " comply with the conditions of this agree t, or if is agreement is modified or cancelled, the <br /> commissa oder shall,notify EHD immediately. <br /> Signature Date <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 />