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SANj AQ j Environmental Health Department <br /> (.61 COUNTY — <br /> ...uw <br /> Greatness grows here. <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 /> Business Name �i Lic. Plate# <br /> Owner/Operator Name � L L� <br /> Business Mailing Address <br /> City Statec�tZip ��215Bus. Ph.� �'L2g (� Alt. Ph. <br /> I, 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 a nalties. C <br /> Signa ure Date J <br /> -- - <br /> 2. To be complet d by COMMISSARY OWNER/OPERATOR` <br /> Commissary Name Y n l Yl U/us # <br /> Addres Y Bus. Phone <br /> City ZiprpaOwner/Operator <br /> Check all appropriate services provided- �/ <br /> wastewater disposal 3-compartment sink CY Electrical hook-ups <br /> pk-70'tt <br /> r 'd waste disposal [3'Food preparation oilet and handwashing <br /> & Cold water for cleaning refrigerated food eicle <br /> le water <br /> tore dry food/supplies Overnight parking 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 fails to comply with the conditions of is agreement, or if this agreement is modified or cancelled, the <br /> commissary w r shall n t fy the EHD imm i ely. <br /> Signature All Date <br /> 3. To be completed bar 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />