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SAN JOANIN Environnnantai Elaalth Department <br /> COUNTY---- <br /> j. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility -% Caterer <br /> Complete sections I and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> F_ I <br /> To be completed by APPLICANT <br /> Business Name Lic.Plate# <br /> Owner/Operator Name �` \Cv <br /> Business Mailing Address <br /> City S-VDCH 6>--!) StateoA Zip vCS 1S—Bus. Ph. C AftPh. <br /> AAka`�6 be,+Om hereby state that the above information is current,'rue and correct to <br /> the best of my knotvledge)and agree to utilize ray approved commissary in accordance %titih CaliforniaCHealth et <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. if the use of Lie <br /> commissary is discontinued,the permit holder must notify the EHD. Failure to notify this ofte may result in perrnit <br /> revocation nd penalties. <br /> SignaturaLDate <br /> F. T® be completed by COMMISSARY OWNEWOPERATOR <br /> Commissary Name A Cc)�f_ i:!,\ <br /> FA# <br /> Pkddress Bus. Phone0-3. 61 <br /> City -��)Vo C�,\CV-�, Zip 01 S Own erlOperator 0 A <br /> Check all appropriate services provided: <br /> i7,111"W' astewater disposal V3-compartment sink OlEk trical hook-ups <br /> "Solid v�taste disposal Food preparation _�C' ilcet and handwashing <br /> Hot& Cold water for cleaning _Z Store refrigerated food ;/P"00 able water <br /> Z7 Store dry food/supplies 7AO'vernight p.arking Vvehicle wash <br /> V� hereby state that the information I have provided is current,true and <br /> correct to the best mko y n vurledge,and meets thet'jalifomia Health 8t Safety Code requirements. Ifithe food facility <br /> ' <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commiss2n/owner shall notify the EHDI immediately. <br /> Signature Date <br /> 13. 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 /> RENS Signature Date <br /> I W8 E. Hazeiten Avenue [ Stockton, California u6205 1 T 209 468-3420 1 F 209 464-0138 j ktr*m/.sjgov.org`1ehd <br />