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SAN JUAQUIN Environmental Health Department <br /> CUUN I 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 - <br /> Business Name Cwt �(' { ��, Lic.Plate# <br /> Owner/Operator Name 1 CLk1 -- <br /> Business Mailing Address 2RO Lalt ►'1L. i -- <br /> City State�'-A Zip li,531UBus. Ph. �c1Glr�i�l3 (C-941t. Ph. <br /> I, f'1Co1 hereby state that the above information is current, true and correct t <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 an penalties. <br /> Signature L&— Date 03-c-, <br /> To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name�x�l c�—1 l J � FA# <br /> Address 3c) rUJ`�,� �� Bus. Phone �S ' 93 I ;033 1 <br /> City Zip C{ S 3 3y Owner/Operator (/n, d ( ``Lr -� C <br /> Check all appropriate services provided: �� <br /> Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies ❑ Overnight parking ❑ Vehicle wash <br /> I ( gyp;>-}�u, 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 /> commissary owner shall noti e EHD immediately. <br /> Signature Date 5 <br /> I <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br /> i <br />