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SANJOAQUIN Environmental Health Depa <br /> rtment <br /> —COUNTY- <br /> - - hreaf.ness aro::. 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.com Ieted by APPLICANT / <br /> Business Name �� r/r 1 /J/n✓cOf Zete_l ic.Plate# /\ <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City. State_ -Zipq Bus. Ph.7o7 &Z 7ZA �It. Ph.70 ' �'7�J <br /> -r�t/O � � <br /> I, �_ , hereby state that the above information is current,true and correct to <br /> the best o my knows ge 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 a enalti . <br /> Signature! (92Date <br /> 2. To completed by COMMISSARY OWNEWOPERATOR <br /> Commissary Name --ri.t . ' FA# uc.der <br /> Address,zue eec Bus. Phone AOq— ;3qA— &)M <br /> Oity 5 t[�k iz.� Zip Owner/Operator n^� •�v �}z.� <br /> Che k all appropriate services provided <br /> - <br /> wastewater�Wastewater disposal ; 3-compartment sink �7F�lectrical hook-ups <br /> [ SSolid waste disposal ❑ Food preparation ISO l ollet and handwashing <br /> 0"ot& Cold water for cleaning Ore refrigerated food 13 Potable water <br /> E3 Store dry food/suppliesOvernight parking ❑ Vehicle wash <br /> I,: t.7nvi'Fy[fy� , hereby state that the information I have provided is current,true and <br /> correct t� stst of my 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. JZ <br /> Signature .� Date JU.'Agr 9G) �n�f� <br /> i <br /> 3. Tobe: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 />