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SAN 1 OAQ U I N Environmental Health Department <br />*, C G U N T Y .._._._... <br />f4 Greotn=>s, grov's her'?, <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 />L1 To be completed by APPLICANT <br />Business Namej t 1 (OS �I M, hMCOS ,K T'( N g Lic. Plate # <br />Owner/Operator Name <br />Business Mailing Address <br />r -a p(- b r- <br />Citv a&Zipq-'�Zj(ZBus. Ph.WC4 4L19 4296AIt. Ph. <br />I, hereby state that the above information is current, true and correct to <br />the b st of my knowledgd 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 r must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature_ Date �� G <br />--- - ------ <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name lV NiA 1 V FA# <br />Addres S • 1( VDf - Bus. Phone w <br />City Zip 3 Owner/Operator r <br />Check all appropriate services provided:/ _/ <br />p/Wastewater disposal W -3 -compartment sink 0 EI trical hook-ups <br />[3,"S olid waste disposal Food preparation T 'let and handwashing <br />EY'H &Cold water for cleaning Store refrigerated food Pot ble water <br />Store dry f od/suppl' s Overnight parking Vehicle wash <br />I , J \lf I� 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 comply with the conditio of this agreement, or if this agreement is modified or cancelled, the <br />commissa o ner hall noti the EHD i ediately. <br />Signature _Date_ <br />> To be completed by the ENV HEALTH;jurisdiction outside of San Joagyin Cqo. <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 Signatu <br />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 />