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SAN J O A Q U I N Environmental Health Department <br /> T. <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 'Comp,feted by APPLICANT L <br /> Business Name C lu Lic. Plate# 0— ID 12 S t� <br /> Owner/Operator Name SiAWALVr 2 <br /> Business Mailing Address 2 W I S <br /> City StateC�A_Zip SED Bus. PhW�3 Alt. Ph. <br /> 1, , 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 ma result in permit <br /> revocation and penalties. <br /> Signatureyrl PO 'Z_ A_,q .�1 i2 'r-L_ <br /> . Date <br /> 12. To,be colrnOfeted by COMMISSARY'OWN'ERIOPERA T OR <br /> Commissary Name <br /> Address930 ' Y n(cA Bus. Phone <br /> City C/ Zip Owner/Operator e-o S <br /> Check all appropriate services provided: <br /> wastewater disposal 3-compartment sink Electrical hook-ups <br /> I- <br /> 01--solid waste disposalq/(0'_0d preparation et and handwashing <br /> r <br /> ot Cold water for cleaning CYStor refrigerated food 'F'o ble water <br /> tore dry food/supplies Overnight parking s Vehicle wash <br /> 1, 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 t comply with the conditions A this agreement, or if this agreement is modifi d or cancelled, the <br /> commissary o er shall notify the EHD im d ately. 2 <br /> Signature0 Date <br /> TvV <br /> 3;. <br /> TO be.caxnplet�d.'by.the ENV HEALTH ulris€ rctt orfisrde of Sin �t� °q>[rr Gor: <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 />