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SAN JOAQUIN Environmental Health Department <br />--COUNTY----- <br />Greatness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility e 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 completedl <br />_�b"A`PPLICANT <br />Business Name <br />n <br />5 vl I' <br />S ad <br />—I—(— e— <br />/� C <br />Lic. Plate # <br />Owner/Operator Name \) A t� 6� `r P- � . <br />Business Mailing Address <br />Cit \Y-�' �St1ate( LZip Bus. Ph.W� gAlt. Ph. <br />I,O�lil( Y i"IU`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 discontin d, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalti�. <br />Signature ,X Date l ! I ( I <br />Commissary Namd:( <br />Address�� <br />Zip M Owner/Operator, <br />Check all appropriate services provided- <br />stewater disposal <br />lid waste disposal <br />U Hot & Cold water for cleaning <br />Store dry fopd/suppli(,A <br />0/3 -compartment sink <br />Food preparation <br />refrigerated food <br />Toilet and handwashing <br />I, -�>A,V\Q A ny— A %VIUV ""yZ�� 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 to l comply with the coned tions of this agreement, or if this agreement is modified or cancelled, the <br />commissa oo-,w er1 rshall nriifgy the E,D immediately. l <br />Signature/ ,J�� V (tel Wj�Y II 1) /IAA Date I '� <br />t/ -V ° 1 <br />3. To be complete6by the ENV HEALTH jurisdiction outside of San Joa` uin 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 />