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j A N J Q A Q U I N Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> (Mobile Food Facility * Caterer <br /> Complete sections 1 and 2. If your cominissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be completed by APPLICANT <br /> Business Name f !/ iL1 Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address IS-461 <br /> City } �' StateZip v Bus. Ph. � �P `' Alfi. Ph. <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 discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pena1ties._1_—- <br /> signatureiC �i ' '� Date 11 -2Z-117 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> L: <br /> Commissary Name %t '' IIC ' Cdr (_, @ FA# <br /> Address ° t' >I �y� Bus. Phone `2 eJt1- <br /> 1 1 <br /> City e > e Zip , S , Owner/Operator <br /> Check all appropriate services provided: <br /> ta Wastewater disposal M 3-compartment sink W Electrical hook-ups <br /> 0 Solid waste disposal ❑ Food preparation Q13 Toilet and handwashing <br /> 1%11 Hot& Cold water for cleaning ❑ Store refrigerated food 154 Potable water <br /> [3 ogre dry food pplies 0 Overnight parking 01 Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the best of my knowle e nd meets the California Health&Safety Code requirements. If the food facility <br /> operator fails comply with th 6nditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa her shall notify e EHD immediately. <br /> Signatur t-L:'� �: t f 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 209 488-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />