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SAN 41JOAQUIN Environmental Health Department <br />—COUNTY— <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 <br />_completed by.APPLICANT 1 <br />Business Name L Lic. Plate # 5 <br />Owner/Operator Name r t�e <br />Business Mailing Address St l't u , 6;W"J V I— - U <br />j2ffi.Alt. Ph. <br />1, hereby state that the above information is current, true and correct to <br />the best of my i<nowledge an ogre 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. �t <br />Sianature Vv [ Date <br />• •- • • - -• o ® i m �" �, ®� <br />FAT <br />Check all appropriate services provided: <br />Vastewater disposal 0 3 -compartment sink 13 Electrical hook-ups <br />Solid waste disposal fwd 'Food preparation diet and handwashing <br />&•Cold water for cleaning €�St e naMgerated food M�able water <br />tore dry food/s pplies Ove rnightparking E�'Vehiclewash <br />I, Y i reby 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 withthe conditions of this a ement, or if this agreement ' modified or cancelled, the <br />commissary gw0er shall nothe EHD immediately. _ r , <br />3. To be com •leted.b `tf e ENIVHEALTH i �Isdtctt©n ot�ts�d:e o. Safi JpeM`uin <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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 484-0138 1 vnvw.sjgov.org/ehd <br />