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SAN J O A Q U I N Environmental Health Department ' <br /> C0U1\1TY <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 �, v.. ` 'rG.Zc" - Lic. Plate#�I <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City State�Zip Q� � Bus. Ph('/-C =i�7-t� �� Alt. Ph ZGoi c <br /> 67 <br /> I, �i�..�a���..J',^ , 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 dis ntinued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and e a ies. <br /> Signature -1/ <br /> Date ��(n <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> FA# <br /> Commissary Name � _1 �� � � '41 e <br /> Address gt 6 /(�ji I ch9,6') i{'y a--,Y Bus. Phone <br /> City Zip ��j Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal -compartment sink XlElectrical hook-ups <br /> Solid waste disposal Food preparation 5,Toilet and handwashing <br /> Hot& Cold water for cleaning iX Store refrigerated food K Potable water <br /> 9R.Store dry food/supplies '�L Overnight parking Vehicle wash <br /> I, ,-)=*'� i"Jt CA}—""1C>" , 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 conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa shall notify the EH immediately. C� <br /> Signature C%: Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin 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 /> 1863 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />