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"x t SANjQAQN Environmental Health Department <br /> ` COUNTY <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 comm feted-by APPLICANT /� n <br /> Business Name \ U� �� Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address � U V(' <br /> City StateOrkZip 59)6 Bus. Ph. Alt. P60� <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 and penalties. <br /> Signature _�` ZI: &Lc A Date 21 _o '- 0 <br /> 2.To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L A C(') '0nP'r C_\ f'\ FA# <br /> Address �ACVAa(\A VGA Bus. Phone <br /> City �)fi O c ��Acv1 Zip 5 2v 5 OwnerlOperatorA ,-n e_-:- <br /> Check all appropriate services provided <br /> 81"W' astewater disposal W"3-compartment sink �T=Iet <br /> cal hook-ups <br /> eolid waste disposal E3 Food preparation and handwashing <br /> � Hot&Cold water for cleaning U Store refrigerated food ;/P�' <br /> ble water <br /> U Store dry food/supplies Overnight parking Vehicle wash <br /> I, ,(�\�1Q� \,e , 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 of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o er hall o the EHD immediately. ' //��' n� <br /> Signatureha - Date_�1� �+, tJ <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />