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SAN 0 A U t N Environmental Health Department <br /> C 0 U I"I i" <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 Lic. Plate# <br /> Owner/Operator Name F <br /> Business Mailing Address PU IRy,C <br /> City 1 Stateckzip�Bus. Ph.209 � 43 Alt. Ph. <br /> I,J4tle— 0�l' 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 ano p4 <br /> Signature Date <br /> 2. To bre completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name —FA# <br /> Address AW U C Bus. Phone-2y <br /> City�j� ip 9S7()� Owner/Operator ?.�T <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink O Electrical hook-ups <br /> / olid waste disposal I Food preparation Toilet and handwashing <br /> of & Cold water for cleaning Store refrigerated food Potable water <br /> Sto foo sup e Overnight parking Vehicle wash <br /> I, , 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 ly th the condi ' ns of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o r s Ufy he EH i tely. <br /> SignatureV. a Date <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 /> .868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />