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SAN 10AQUIN Environmental Health Department <br /> -- -COUNTY— <br /> Greotness oro,vs here. <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� Lic. Plate#�� <br /> Owner/Operator Name <br /> Business Mailing Address Z l2�c� -�4 C+ <br /> City I–OD) StateCh zip Bus. Ph. L010­62WAit. Ph. <br /> I, re 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 penalti U <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName 1 ofy)M1S_&1% A2, f'l FA# <br /> Address LD2 0 S ` CCG S 1 Bus. Phon <br /> City LOAZip '�t5?-`{() Owner/Operator ��2��clCc� � l�1cG �NG�C1C nkc(Cj <br /> Check all appropriate services provided: <br /> tg Wastewater disposal q 3-compartment sink f Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation )ff Toilet and handwashing <br /> [�Hot &Cold water for cleaning `P Store refrigerated food V Potable water <br /> ❑ Store dry food/supplies FI Overnight parking �t Vehicle wash <br /> I, cpiAL `N � (-OCOGhereby state that the information I have provided is current,true and <br /> correct to the best my knowledge, ah1d 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 t EHD immediately. <br /> Signature Date <br /> 3. To be com leted by the ENV HEALTH jurisdidon 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.sigov.org/ehd <br />