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SAN JOAQUIN E-rivironmental Health Department <br /> --COU NTY— <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 /i I Lic.Plate# 5 <br /> Owner/Operator Name _dM1 e <br /> Bu 31 e s Main Address <br /> Cit Ste Zip 2 Bus. PhW 1 Ph. <br /> I, rzi hereby state that the above information is current,true and correct to <br /> the best of my knowledge an agre 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)ay result in permit <br /> revocation and penalties. n <br /> Signature 1n t— Date � l� <br /> 2. To be completeo completeby COMMISSARY OWNER/OPERATOR <br /> Commissary Name <br /> Address 1 t- Bus. Ph e ' <br /> City Zip J Owner/Operator Rqc <br /> Check all appropriate services provided <br /> &-Vrastewater disposal 3-compartment sink Of Electrical hook-ups <br /> Solid waste disposal i�od preparation CVfoilet and handwashing <br /> G.t"Hot &Cold water for cleaning C St e refrigerated food M�able water <br /> 1:1tore dry food/s ppliiees O ernight parking O<ehicle wash <br /> I, Yeby 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 wit the conditions of this a ement, or if this agreement ' modified or cancelled, the <br /> commissary w er shall no i the EHD immediately. �Ie , or /� <br /> Signature �r u�QAA 44 \ Date (i <br /> 3. To be completed by the ENV HEALTH junsd& tion'outside of San Joa uin 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 vmw.sjgov.org/ehd <br />