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SANAAQUIN Environmental Health Department <br /> —COUNTY— <br /> c�� r Grectness grows here. <br /> COMMISSARY AGREEMENT / <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 . Tobe com feted b _APPLICANT <br /> Business Name U Lic. Plate# L 5 <br /> Owner/Operator Name rr11 Y <br /> Business MaliCt 19\ <br /> Address LV <br /> ca <br /> CitY StZi Bus. P90 "Ll Z UIt. Ph. <br /> I. '�V 0 1 Q a P , 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 pe ' holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation andenalties. <br /> Signature Date 1' <br /> 2:.To be om p feted by COMMISS RY OWNER/OPERATOR o _ <br /> Commissary Nam ) 1 In ` kJ� <br /> Address I Bus. Phone 2 <br /> City Zip "2L Owner/Operator <br /> all appropriate services provided:Vrstewater disposal ®'3- mpartment sink � ctrical hook-ups <br /> Sol <br /> waste disposal ; Fo:preparation /Toilet and handwashing <br /> ♦� Cold water for cleaning ■ S e refrigerated food Po ble water <br /> S e d=foodppli s Overnight parking Vehicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> correct to the best of my (nowledge,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 r all/nnq2ffy th HD immediately r� <br /> Signature u�.���b�'„�' Date <br /> 3..To be com feted b the ENV HEALTH jurisdiction outside of San Joa uin Co. 1 <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 />