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`r `u SAN.310AQU1N Environmental Health Department <br /> CCU NTY___... <br /> Greatness grows here. <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_complbte APPLICANT _ %� b <br /> Business Name el) Lic. Plate## <br /> Owner/Operator Name <br /> Business Mailing Address zh/ <br /> City -St rjjby7 State�% Zip 52( Bus. Ph. 9ZS-320 55SSAlt. Ph. <br /> I, ,&a'2& A/�4 , hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agreefo 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 alties. <br /> Signature �A , Date /-2 <br /> yCOMMISSARY OWNER/OPERATOR p� <br /> Commissary Name <br /> Address 7 5, S Bus. Phone -- <br /> City S-Li<In Zip� b �7, Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal P/3-c mo partment sink , le—ctriical hook-ups <br /> Sol' ste disposal 13 Food paration d'Toilet and handwashing <br /> �tore <br /> Cold water for cleaning �vernight <br /> �rigerated food otabl ater <br /> dry food/supplies m parking ehicle wash <br /> I, ��i�Q G Y l�E3tilV�`T3'C.�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 cbply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary hall tify t EHD immediate'. <br /> Signature _ Date <br /> 3. To be completed :by the ENV HEALTH jurisdiction outside of San Joaquin_CoJ). <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 />