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, Q ��� Environmental Health Department <br /> COUN T Y <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 completed by APPLICANT <br /> Business Name Lic. Plate# / <br /> Owner/Operator Name rL) ,� 'rF,') A- <br /> Business Mailing Address �1, \J 141 p o e J�a1,_ <br /> City OC. State if)4/Bus. PiC - Ph. <br /> I, hereby state that the above information is current, true and correct to <br /> the best of my know edge 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 holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penaities,. ) <br /> Signature ,r/�l i. ,7-t/ Date <br /> i/ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Cornmissary Name <br /> AddressZ3Bus. Phone-/-I,---,q Z_-4/ q,- <br /> City 557 ,kjCn�j� Zip �s�,CZ� Owner/Operator !� <br /> Check all appropriate services provided: <br /> j-Wastewater disposal e -3--compartment sink tI_EleOcal hook-ups <br /> O'Sojd waste disposal P'Food preparation10'_Toi�et and handwashing <br /> Q Hot & Cold water for cleaning Store refrigerated food 6 Pot�bV­water <br /> tore dry food/su lies M- Overnight parking [Vehicle wash <br /> I. d teu _, 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 mply with the conditions of thi4areement, or if this agreement is modified or cancelled, the <br /> commissary o�nln shall no ' th HD immediate �L 1 <br /> Signature jj Date <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 l Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sj'gov.org/ehd <br />