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SAN JOAQUIN Environmental Health Department <br /> COUNTY-- <br /> s h e e. <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 <br /> Business Name Lic. Plate <br /> Owner/Operator Name R MA i Z S'lIQ G H ;� <br /> Business Mailing Address /p-� I W I I/1-�'py1� Din <br /> City NI3LI%E Ca- State (A Zip q53.3-1- Bus. Ph.�Qg-q5( �lt. Ph. 4�0 q- <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, the permit holder must notify the EHD. Failure to notify this office;may result in permit <br /> revocation and penalties. 6?I <br /> Signature. A ��T � [ � 6? � Date <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name 1 cK A/ 5-b 9ct �3 P m FA# <br /> co <br /> Address 31-0a a L M rJ a V i✓ Bus. Phone _q w 0 <br /> City S'i o Cl-1 ion/ Zip CA G saz,S Owner/Operator 0 N Z <br /> Check all appropriate services provided: O M0 <br /> j2 Wastewater disposal _ED 3-compartment sink _"N­l Electrical hook-ups Z Z — <br /> Toilet and handwashing D rnFood preparation waste disposal n <br /> `2 Hot & Cold water for cleaning Store refrigerated foodPotable water CD > x <br /> 0 Store dry food/supplies Overnight parking M Vehicle wash p m D <br /> to ic <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 . a� ,<�—'=; Date /D,-- <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 />