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A �) , Environmental Health Department <br /> --COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ,t 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 NameI Lic. Plate# <br /> Owner/Operator Name A ~ <br /> Business ailing Address J E '� <br /> City <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, t permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p nalties. <br /> Signature Date l / <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name C !:. e�E')^'► FA# <br /> Address 39 I'a E .n/1 i n/ ER 43 V 6 Bus. Phone G— CAvk -- 1'1 1A c! <br /> City Zip Owner/Operator <br /> —IwC <br /> Check all appropriate services provided: 0O m <br /> ® Wastewater disposal 0 3-compartment sink Electrical hook-ups m Z <br /> ® Solid waste disposal 0 Food preparation NQ Toilet and handwashing O � QO <br /> z <br /> ® Hot & Cold water for cleaning ""U Store refrigerated food d Potable water m 0 <br /> Store dry food/supplies �'U Overnight parking © Vehicle wash D X 0 <br /> I, hereby state that the information I have provided is current,true and al C M <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility M D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the 0 <br /> commissary owner shall notify the EHD immediately. <br /> Signature � ir,� L.`-�,� S;�' Date y— yl— !3,i <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 />