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SAN )QaQUIN Environmental Health Department <br /> —COU NTY— <br /> `ireotness grows flare. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 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 2 <br /> Business Name K C"P, I�IQCXA('— Lic. Plate# , <br /> Owner/Operator Name S sap <br /> Business Mailing Address s <br /> City Statef,6_Zip a J -tb Bus. Ph.W T "l- FV('C I Alt. Ph. <br /> I, c 7VZ V v1 $->a hereby state that the above information is current, true and correct to <br /> the bjsj 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 disco i the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and kyaI <br /> Signature DateLAO <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 01 It �'f n r �� F2� svQgl h FA# <br /> Address__2 V V E) S. AUrPo r C,,f Bus. Phone Z d 5_6 I — /Y6 6 <br /> City 54-0c V0-0 1 Zip 5 CZ(2Owner/Operator <br /> Check all appropriate services provided: <br /> [a Wastewater disposal Q 3-compartment sink Electrical hook-ups <br /> a Solid waste disposal L,� Food preparation 5rToilet and handwashing <br /> 51 Hot & Cold water for cleaning Store refrigerated food lit Potable water <br /> g! Store dry food/supplies 0( Overnight parking R Vehicle wash <br /> I, e (:_�_ 1Z kl , hereby state that the information I have provided is current, true and <br /> correct to the est 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 /> Signature T �'" Date�/ Z L /Z / <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 />