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SAN JOAQUIN Environmental Health Department <br /> ----COUNTY-- <br /> COMMISSARY <br /> --COUNTY---- <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 /> 11 . To be completed by APPLICANT / <br /> Business NameV Lic. Plate# <br /> Owner/Operator Name ~oV km <br /> Busi ess Mailing Addr ss 532 <br /> Cit to ipBus. Ph2P Alt. 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 Envealth Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the permit Ider must notify t EHD. Failure to notify this office may result in permit <br /> revocation an enalties. <br /> Signature Date f, )DD <br /> 2. To be com.Oletodby COMMISSARY OW. EMPERATOR <br /> Commissary Na G 20 1 �b <br /> Addres n Bus. Pb—one Mct Z 1 <br /> City �— Zip Owner/Operator t f) <br /> Check all appropriate services provided.- <br /> wastewater disposal Y-compartment sink Electrical hook-ups <br /> Solid waste disposal 0/'Food <br /> SFood preparation Toilet and handwashing <br /> :W_H old water for cleaning Zernight <br /> refrigerated food potable water <br /> .Store dry ood/supplies parking Vehicle wash <br /> 0 <br /> I, , hereby state that the information I have provided is current,true and <br /> correc to the best of my 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 ner sh notify the EHD i ediately. <br /> Signature Date <br /> 3. To be::`�' r t#ety tEALT F <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 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />