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SAN J OAQ U I N Environmental Health Department <br /> --COUNTY <br /> Greotness grows here. <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 <br /> completed by APPLICANT <br /> Business Name �\ ��j (,� S L (od D Lic. Plate# S-A kq (,Y` <br /> Owner/Operator Name \a,)yt tN Y`' lZ h A- <br /> Business Mailing Address 13L-uc4TZAs L,�-, . <br /> City State LAZip Bus. Ph. Alt. Ph('L'A, uo –fLkJA <br /> I, \ N mn.in A-K , 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 ~ Date �C <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name i ! ,n FA# <br /> Address Bus. Phone <br /> City t Zip L: C- Owner/Operator <br /> Check all appropriate services provided: <br /> /astewater disposal ir3-compartment sink [�'Electrical hook-ups <br /> r=!'Solid waste disposal d Food preparation Toilet and handwashing <br /> ' Hot & Cold water for cleaning 11 Store refrigerated food 0�Potable water <br /> .`7 Store dry food/supplies Ur Overnight parking WVehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the best 6f 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 immediately. <br /> Signature— '+ Date S Z <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />