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SAN J OAQ U I N Environmental Health Department <br />-- COUNTY ---- <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 :f= Cd F� i i -> _Lic. Plate <br />Owner/Operator Name t-9 42 6 s <br />Business Mailing Address l c/ S i s vfvhr. rH c ) <br />CityC Io K/<n State C��_Zip ' 1�1,? C Bus. Phf2�R) 9b5 2S44Alt. 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 oenalties- <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName L,� 114-Vfn 1 a <br />Address ;7-4'VU S. krour-I- Ujc� Bus.Phone <br />City S�0"v IU✓( Zip q C'Z, y (, Owner/Operator <br />Check all appropriate services provided: <br />®" Wastewater disposal It 3 -compartment sink IW Electrical hook-ups <br />ar Solid waste disposal Food preparation M Toilet and handwashing <br />M Hot & Cold water for cleaning Store refrigerated food Id Potable water <br />15( Store dry food/supplies IA Overnight parking Ek Vehicle wash <br />I, '.e g S —_2 ✓ int o 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 />Signature °-t _ Date�� f 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.sigov.org/ehd <br />