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SAN JO A Q U I N Environmental Health ©epartrne n�� <br /> COUNT`! <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 /J <br /> Business Name 71:5 .re-y i117 Cr // Lic. Plate# ,?cr SSO <br /> Owner/Operator Name <br /> Business Mailing Address 17 0 S N 1.r=cc �i hr G'f` <br /> Citycj 2C-_L' 11 State(-4Zi 52C L Bus. Ph-�_6-t-�J I FJ 363"zAlt. Ph. <br /> I, Tc <br /> '6.11 c J n C-)— , 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 /> revocation71---1 <br /> d penalties. �7 <br /> Signature ((`} 2 L �? �Z Date 21L-2 2 0 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName FA# <br /> Address W—7 Bus. Phone `I - SC-. I <br /> City Siyc Zip fj C 2,� Owner/Operator <br /> Check all appropriate services provided: <br /> 'Wastewater disposal [3'3-compartment sink D'Electrical hook-ups <br /> Z Solid waste disposal ly Food preparation 7rToilet and handwashing <br /> �:'J Hot & Cold water for cleaning 2'Store refrigerated food Potable water <br /> Store dry food/supplies L—/Overnight parking Z Vehicle wash <br /> (-;- 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. l <br /> Signature Date Z / Z� �Zc <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />