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SAN OAQUIN Environmeniai Health ®epartme�fi <br /> —COUNTY-- <br /> _, i>r2ntness yrG'rrc Lere. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility r 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 /> r 1/ <br /> Business Name 0,/Lt � Kms- IG644 Lic. Plate# Roo gZ-TL <br /> Owner/Operator Name r, 'L S �' t'L> <br /> Business Mailing Address Q—A' <br /> CityS,LCIC -✓n State_LQZip q S Bus. Ph. Alt. Ph. <br /> bI, , hereby state that the above information is current,true and correct to <br /> the best of my owledge 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,thelpermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signaturee. Date 3 3 <br /> 2. To be completed by COMMISSA,yRY OWNER/OPERATOR <br /> Commissary Name 0,0 I �w n l� ��9✓iT�1�+a FA# <br /> Address 2A/VO S, ,4irprj f�+� Bus. Phone 70 � — �6/ � � V'6!6 <br /> C � <br /> City rA),)A Zip Owner/Operator J� He a <br /> Check all appropriate services provided: <br /> Q Wastewater disposal 06compartment sink Electrical hook-ups <br /> LK Solid waste disposal Ire Food preparation ik Toilet and handwashing <br /> OK Hot & Cold water for cleaning Id Store refrigerated food U Potable water <br /> Store dry food/supplies Overnight parking Pi Vehicle wash <br /> 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 notify the EHD immediately. <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />