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SAN JOAQUIN Environmental Health Department <br /> --COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 com leted by APPLICANT <br /> Business Name �� ic.Plate# L I <br /> Owner/Operator Name <br /> Business Mailing Address -1/�G! -7 t�(I f C� 0 �R <br /> City_' � Ck � StateZip Bus. Ph.Zlg/ 9� �17Z j Alt. Ph. <br /> I,PO� P f LA- hereby state that the above information is current,true and correct to <br /> the best of my knowled a 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 pen / <br /> Signature Date a <br /> 2. To be com leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L A Cc) Mex-c. rA \ FA# <br /> Address rVAMIa IJC,N Bus. Phone agOG Z_/ {)&I L�S 7o <br /> City 1D+O C 4AJ Ov1 Zip I'S ?7o 5 Owner/Operator <br /> Check all appropriate services provided: <br /> jz'*�Wastewater disposal 0/3-compartment sink � EI ncai hook-ups <br /> /olid waste disposal 13 Food preparation T flet and handwashing <br /> 0 Hot&Cold water for cleaning ® �Store refrigerated food � able water <br /> 0 Store dry food/supplies lYOvernight parking 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 to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediatei . 11 0 <br /> Signature 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 /> 1868 E. Hazelton Avenue I Stockton, California 96205 I T 209 468-3420 1 F 209 464-0138 1 www_sjgov.orgfehd <br />