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SAN 1 a A Q U I N Environmental Health Department <br /> COUNTY--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 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.com leted by APPLICANT <br /> Business Name Lic. Plate# <br /> Owner/Operator Name A <br /> Business Mailing Address S GG <br /> City <br /> 1, �j�� eJgi� t , hereby state that the above information is current,'true and correct to <br /> the best of my knowledg6 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 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> L <br /> Commissary Namex'k. FA# <br /> Address�l�'0 C Bus. Phone, 19 <br /> city L ,c Zip S- b Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal td 3-compartment sink Electrical hook-ups <br /> 156 Solid waste disposal E3 Food preparation Toilet and handwashing <br /> Hot& Cold water for cleaning 13 Store refrigerated food Potable water <br /> 0 S e dry food/ plies � overnight parking Vehicle wash <br /> hereby state that the information 1 have provided is current, true and <br /> correct to the best of my knowledge,and ee the California Health&Safety Code requirements. If the food facility <br /> operator fails c mply with the con of this agr ement or if this agreement is modified or cancelled, the <br /> commissa p(ow0je,shall notify the i mediately. ,- <br /> Signature «l % Date "2- <br /> 3. <br /> 23. 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 F 209 464-0138 1 www.sigov.org/ehd <br />