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SAN JDAOUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 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 corn leted by/�APPLICANT A <br /> Business Name l i:�4. Lic. Plate# 7'77 v% <br /> Owner/Operator Name 1Y(. - <br /> Business Mailing Address 1% <br /> City 6 s State��Zip�s. Bus. Ph.aG�- 5/-%G 'Alt. Ph. <br /> I, c ` 1YPAit//��C l Z= )V , 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 p r it holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature I Z YdC �'r Date <br /> 2. To be completed b// COMMISSARY OWNERIOPERATOR <br /> Commissary Name ( J�r11 / FA# <br /> Address e-c�6e f Bus. Phone <br /> City Zip caner/Operator, %J, `'7kf,al <br /> Check all appropriate services provided: <br /> Wastewater disposal :1 3-compartment sink `V- Electrical hook-ups <br /> tj Solid waste disposal Food preparation Toilet and handwashing <br /> Hot& Cold water for cleanings Store refrigerated food Potable water <br /> tare dry food/supplies Overnight parking Vehicle wash <br /> 1, G , hereby state that the information 1 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 comply with the bnditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissarowner shall notify EHD immediately. <br /> Signature y, L� Date <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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />