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SAN JOAQUIN Environmental HeaRh Deparh-uisnt <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_r"'� A<Q S C o S 1 p�A1_NS 1-_N ni Lic. Plate# 3101 Y <br /> Owner/Operator Name C P S T <br /> Business Mailing Address 7-6 5 CJ ZA 2-t,,- C�-, <br /> City �V-(DCA�ro.,J StateC/� Zip ` X21 �_ Bus. Ph.Z©j S?d 6N& Alt. Ph. <br /> I, 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 7n �,S �� .S � o n 1 C4 2 Date 12--.� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 6_�� I >� n �- ��e= f-aJ �, �, 3-t,0 r21�;, FA# <br /> Address Al ^ �� Bus. Phone 2✓ ` — 7 I - = <br /> City : l_ ?-c"i' Zip e;,5; ,7 c t Owner/Operator <br /> Check all appropriate services provided: <br /> 0-<Nastewater disposal fL�compartment sink +-Electrical hook-ups <br /> ,c Solid waste disposal FY- Food preparation .;Toilet and handwashing <br /> 1-2'Hot & Cold water for cleaning L-3/Store refrigerated food L-!�Potable water <br /> �Store dry food/supplies Overnight parking ;Vehicle wash <br /> I, 2�.r L l'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 comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall noti the EHD immediately. <br /> r <br /> Signature _ Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 46�' .'1138 1 www.sjgov.org/ehd <br />