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SAN.DJOAQUIN Environmental Health Department <br /> C 0 UNIIT Y <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 /> 1: To be-- ----P(1e-t6d,,'&yAPPLICANT 77 <br /> Business Name L IZE, 1-1-h Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address \9) <br /> Citv'�;Wjln StateZip Bus. PhILOS) 5S)VAlt. Ph. <br /> 0\\t4 At) r N UMIn hereby state that the above information is current.true and correct to <br /> the bet'of my knowledge Wd agree to itilVe 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 Date <br /> 2. To be,6ornplete d- by COMMISSARY OWNEWOPIE-k0l <br /> Commissary Nam& fpff <br /> AddreSs:�41 0. f-A f APO U -Bus. Phone ?_0 <br /> rr <br /> CityziSA-t y�) p T T�Owner,/Operator by 1 <br /> Check all appropriate services provided: <br /> (3/Nastewater disposal 0--3--compartment sink GrIa"Iectrical hook-ups <br /> U/S lid waste disposal P"�Fcod preparation D/Tollet and handwashing <br /> 1;/�Hqo & Cold waterfor cleaning �Stoj e refrigerated food �Xpalblewater <br /> I S food <br /> o :PZ yOvernight parking Vehicle wash <br /> �7, 7/,;,1 ie.,44,ot� hereby state that the information I have provided is current, true and <br /> correct to the best of myno_wleclge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails <br /> 90 y f I t mp I with the conditions of this agreement, or if this agreement is modifie or cancelled, the <br /> o <br /> commissary o r. all nojify h HD immediate)y. <br /> Signatur -Date <br /> HI=ALTH'unsdlcton�outs►cie3ofSan"Joasuln 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 wvvw.sjgov.org/ehd <br />