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SAN -JOAQUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer , <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To oe eornpjeted by APPLICANT t C <br /> Business Name I S c. Plate# 3ZSS <br /> Owner/Operator Name W <br /> Bus' s Maili/ng ddress QQ q <br /> City ✓� a (Zip �� Bus. Ph. �6 ,S V Alt. 405 b�L I <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 discont d4 the ermit hoIde ust notify the EHD. Failure to notify this o ice may result in permit <br /> revocation and pe al i <br /> SignatureL /l/ Date <br /> 2. To be cornplet ,- CE?MMlSSARY OW ."PERATOR - — <br /> Commissary Name I t i (#� k'' ` <br /> Address L_ Bus. P one 2 I <br /> Cita (,�C 17> Zip�Owner/Operator Q /1 (� o <br /> Check all appropriate services provided: <br /> El-Wastewater disposal compartment sink D Electrical hook-ups <br /> slid waste disposal food preparation d_—Toilet and handwashing <br /> El Hot& Cold water for cleaning 03tore refrigerated food G-Potable water <br /> 12—re d food suppli s 0-15v�ernight parking O'V�ehicie 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 corn ly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o r all n fy th HD immediately. �7 <br /> Signature Date <br /> ILI 2- 1 <br /> 3. ?To be cQfripleted lijf the ENV€ EALTH juri. <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 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br />