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S A N J Q A Q U I N Environmental Health Department <br /> --COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. if your commissary is located outside o;San Joaquin County also complete section 3. <br /> 1. To be com leted by APPLICANT <br /> Business Namel 6 ­�I Lie. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address -/67 <br /> City State Zip 5 Bus. Ph. 33d�_ /o Alt. Ph. <br /> a a%,'/� ,X�u nA/3 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, th rmit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalti <br /> ` <br /> Signature Date 31124 <br /> 2. To be completed b COMMISSAR OWNER/OPERATOR <br /> Commissary Name xa FA# <br /> Address ���� ` t Bus. Phone))OZ - ZI&q -!q LW <br /> City Zip ' Owner/Operator { r <br /> Check all appropriate services provided: <br /> -,: Wastewater disposal 3-compartment sink Electrical hook-ups <br /> +_ Solid waste disposal iz Food preparation _ Toilet and handwashing <br /> Hot& Cold water for cleaning M Store refrigerated food f--j Potable water <br /> SeJe dry food/sutp�plies r Overnight parking 72 Vehicle wash <br /> I ./i ,��i�_ /-,FX/I�/�/i,(G -Z—' , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and ets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the co ions of this agreemprit, or if"this agreement is modified or cancelled, the <br /> commissary n r shall notify the mediately. <br /> Si nature �t t� CSG , Date J <br /> 9 <br /> 3. To be completed b the ENV HEALTH jurisdiction outside rpt San Joaquin Cv. <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 END if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 `` 209 468-34201 - 209 464-0138 1 www.sjgov.org/ehd <br />