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SAN JOAQUIN Environmental Health Department <br /> -----COUNTY----- <br /> COMMISSARY <br /> ---COUNTY----COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections ? 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 c. Plate# 8 0N B <br /> Owner/Operator Name l <br /> Busine s Mailing Address �i <br /> City Sta eZip�Bus. P L� Alt. Ph. <br /> , <br /> 01 Olk"l—n , hereby state that the above information is current, true and correct to <br /> the best of my knowledg 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 I`�GY'�c� R N�0.M 0�9y1'e�lSy ' Date W <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name <br /> Uk Lk k)�'&V_a& I <br /> Addr s Ir �� _Bus. Phone �I <br /> City Zip Owner/Operator 6V <br /> Check all appropriate services provided: <br /> tewater disposal;P0'3-compartment sink q-1 lectrical hook-ups <br /> olid waste disposal mod preparation Toilet and handwashing <br /> Qlf of & Cold water for cleaning amore refrigerated food 0 Pota le water <br /> El Store dry food/supplies vernight parking Vehicle wash <br /> 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 fai s to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissarf jowner shall notify the E immediately. <br /> SignatureWy _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 /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 E 209 464-0138 1 www.sjgov.org/ehd <br />