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SAN JOAQUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections I and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> _ <br /> Business Name I 'I,t�6_SdQn \ Is Lic. Plate# ✓ J� <br /> Owner/Operator Name <br /> Busine s Maiiin ddress /�� <br /> C� tat Zip_OBus. PI� 420 9Z"lVAlt. Ph. <br /> 1, 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 liolder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a enaltie n � I <br /> Signature o Date [� <br /> 2. To be completo W COMMISSARY OWNER/OPERATOR <br /> Commissary Nam <br /> Address I Bus. Phone L <br /> City )/�� Zip ��3 Owner/Operator Y � 'f r� <br /> Check all appropriate services provided <br /> /Wastewater disposal 0'3-compartment sink CF'E--Iectrical hook-ups <br /> C Solid waste disposal Food preparation P-Toilet and handwashing <br /> 0`14ot & Cold water for cleaning Q St//ore refrigerated food Mable water <br /> CP9t'Q e d foo suppli s LYOvernight parking QXehicle wash <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 com ly with the conditions of this agreement, or if this agreement is modifi d or cancelled, the <br /> commissary o r all n tify th HD immediately. n <br /> Signature Date L <br /> 3 To be.c #eted;by the ENV HEALTH iurisdiction outside Q# 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 />