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FA# <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUN <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 JCO <br />Owner/Operator Name yo f A Co <br />Business Mailing Address I /(;)_cl -1 A (i2c) <br />City 'JD -1;-()n Statelk Zip Bus. Bus. Phi2cs-3 Alt. Ph. <br />I, VU r 3S A CaA- , 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,. <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name <br />Address I Z -C; ,ce/d 20 I-71— Bus. Phone <br />Zip (-)'//,..) Owner/Operator ("4,47 r/ {) i l . / M 07 ) City (11.Z <br />Check all appropriate services provided: <br />ca-Wastewater disposal 0 3-compartment sink EP/Electrical hook-ups <br />Solid waste disposal 0 Food preparation WToilet and handwashing <br /> <br />1 Hot & Cold water for cleaning 0 Store refrigerated food grPotable water <br />0 Store dry food/supplies Erovernight parking p- Vehicle wash <br />I • <br /> <br /> 4 /;0 e//t) / /z-i/-g4 ) r- ---- , hereby state that the information I have provided is current, true and <br />) —7,- <br />correct to the best of my knAedge, 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 noffy -the ED i rKediately. <br />Signature Date ()7/ <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 END if the status of their operating permit changes. <br />REHS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Lic. Plate # <br />Date <br />