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PQ 'S y 3SS :�; <br /> SAN J OAQ U 1 N Environmental Health Department <br /> -couiyTY <br /> �5 9"" >, . <br /> o0 S `� I <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 pa-rh begn)/r C.f ay S Lic. Plate# <br /> Owner/Operator Name J//Yl Gt 1 ..54 1 l� Z <br /> Business Mailing Address Y/y J 01�i (< ,�Q <br /> City �f©G StateZip _BBus. Ph.2�Q �Q&'Ll'///s Alt. Ph. <br /> c S ,'t tie Z 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 disco - ued, the perm' holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pena ie.- . <br /> Signature Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> CommissaryName ? 1Q )< ey G'o CREp� FA# <br /> Address 3 N I i iv6W A Vc Bus. Phone^ CktA?-- /7 (A g <br /> City Zip Owner/Operator <br /> w <br /> Check all appropriate services provided: p X <br /> p Wastewater disposal Ll 3-compartment sink M-Electrical hook-ups N Z <br /> C] Solid waste disposal E3 Food preparation Toilet and handwashing p In O <br /> 30 <br /> C] Hot & Cold water for cleaning 23-Store refrigerated food 0 Potable water Z Z n <br /> MM <br /> C3 Store dry food/supplies PY6vernight parking C] Vehicle wash D X n <br /> I, hereby state that the information I have provided is current, true and to < X <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. If the food facility G M D <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the c <br /> commissary owner shall notify the EHD immediately. <br /> Signature - Date <br /> 3. To be completed by the ENV HEALTH jurisdiction 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 www,sjgov.org/ehd <br /> 15 <br />