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S A N J O A Q U IN Environmental Health Department <br /> --- C O U N 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 s <br /> Business Name Lic.Plate# <br /> Owner/Operator Name *f ;5, A CD <br /> Business Mailing Address A 1J-/- - PtfSA- Vc� <br /> City�.)D " �ko n StateLZip_c1,S�LgBus. PhU•,Q0 Q6!�_Alt. Ph. <br /> I, , U f SS A C )i-o , 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, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature,_ _ Date -7` <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name i ifJ i 1 FAQ <br /> Address ,( 'G/ f Bus. Phone <br /> CityL14 Z Zip Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal ❑ 3-compartment sink E;YElectrical hook-ups <br /> 1 Solid waste disposal ❑ Food preparation EVToilet and handwashing <br /> P Hot & Cold water for cleaning ❑ Store refrigerated food LVPotable water <br /> [3 Store dry fo d/su plies Overnight parking Vehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correct to the best of my kedge,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 /> commissary owner shall notify the EVD i diately. <br /> Signature Date <br /> F3, o be completed by the EW"HEALTH jurisdiction outside of San Joaquin Co. i <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 /vw.sjgov.org]ehd <br />