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SAN ,JOAQUINp i f <br /> Eti�\�iron��en'�aI Health i-�e �I("t.�rtl:sa'atftl <br /> --COUNTY <br /> Greotness arc ,, her. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 9 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 q� <br /> Business Name o.M h.1 *G 6=g4 —Lic.Plate# Roo o y ZT L <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City/ ��Gk 1✓n State�Zip q jQ_�Bus. Ph. Alt. Ph. <br /> C/ <br /> I, OL , hereby state that the above information is current,true and correct to <br /> the best of my kdowledge 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 &-",z _ -z i- Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 0& i �tPn 4� ���✓iy1�+a FA# <br /> Address 2-1111/0 S, . irp2rl WF!�; Bus. Phone 'A2� - <br /> City !64�rAl-i t ZipT2,;24 Owner/Operator <br /> a <br /> Check all appropriate services provided: <br /> q Wastewater disposal M"�3-compartment sink k Electrical hook-ups <br /> LX Solid waste disposal N'Food preparation Me Toilet and handwashing <br /> I( Hot & Cold water for cleaning Id Store refrigerated food -W Potable water <br /> jif Store dry food/supplies Overnight parking Pil 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 A _ <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 />