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I SAN iJ OAQ U IN Environmental Health Department <br />--COUNTY <br />'.acFoa'Greatness grows here. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections f 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 oq K Lic. Plate # <br />Owner/Operator Name %S i j J"i <2✓ Vii' e <br />Business Mailing Address 1 / e-st.V •Rv ✓ 3?0 <br />City State�Zip 9s% Bus. Ph. �D9 N�1'��It. Ph <br />I, , 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 penalties. <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name D C -L CRC -]0(X-7 FA#_ <br />Phone a -Q— QWt--1'1 kAG <br />City -9 7-o C M 7-0 &,- Zip cA et s`to S Owner/Operato <br />Check all appropriate services provided: <br />❑ Wastewater disposal ❑ 3 -compartment sink <br />❑ Solid waste disposal 0 Food preparation <br />❑ Hot & Cold water for cleaning ["tore refrigerated food <br />❑ Store dry food/supplies W6vernight parking <br />IW,Electrical hook-ups <br />f -Toilet and handwashing <br />O Potable water <br />0 Vehicle wash <br />I, , hereby 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 with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately. <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 />IMIME 9 <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 />