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3A N J OAQ U I N Environmental Health Department <br /> -COUNTY----- <br /> her--. <br /> OUNTY-__•-. <br /> her:. <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 "ACA(.0 L GvM�X Lic. Plate# <br /> Owner/Operator Namen� <br /> Business Mailing Address r Fv,) <br /> City; AAL) State o ff Zip Bus. Ph. ?{i�l� Alt. Ph. <br /> I, M• ( ] o�;ay 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 pen (ties. <br /> Signature !' Nle ! '� Date z <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary NameF ' k i.n - �1 �Le f 1`'l FA# <br /> Address 2 NO 5. A ? Bus. Phone ' C> <br /> City Z_4-0� t�_('I\ Zip e- Owner/Operator <br /> Check all appropriate services provided: <br /> )ci Wastewater disposal 13-compartment sink EXElectrical hook-ups <br /> Solid waste disposal M Food preparation V Toilet and handwashing <br /> Hot & Cold water for cleaning 4A Store refrigerated food Potable water <br /> [5(Store dry food/supplies Overnight parking Vehicle 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 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 /> Signatures - .... 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />