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SAN J OAQ U I N Environmental Health Department <br /> C O U 1\1 T Y---- <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+b APPLICANT <br /> Business Name �2 U ti tek0 () Lic. Plate# r-1 U C L T <br /> Owner/Operator Name r,f-" <br /> Business Mailing Address ab v W m oc,)^ r'ay-,,P. YSt <br /> City '��,�r� State Cly Zip 2l Bus. Ph. 4� Alt. Ph. <br /> C <br /> I, C sk�_r C-C-Mcfl _ hereby state that the above information is current,true and correct to <br /> the best o 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 �Ities. j <br /> Signature y Date 1 Z�17 1 Zc7 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ' FA# <br /> Address /?LIZ/ S r -f Bus. Phone — ,� <br /> City �f�dl� Zip G Owner/Operator v 11%'41W& <br /> & <br /> Check all appropriate services Provided: <br /> )o Wastewater disposal C' 3-compartment sink Electrical hook-ups <br /> ISolid waste disposal ® Food preparation Toilet and handwashing 17 <br /> Hot & Cold water for cleaning C] Store refrigerated food Potable water <br /> Stored food/ upplies " Overnight parking Vehicle wash <br /> P , hereby state that the information I have provided is current, true and <br /> correct to the best of my kno ge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply witff the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall the HDi tely. <br /> Signature Date <br /> 3. To be completed by the 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 209 464-0138 1 www.sjgov.org/ehd <br />