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SAN 10AQUIN Environmental Health Department <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 22 <br /> Business Name V Lic.Plate#_ J <br /> Owner/Operator Name <br /> Busin s Mali��wAddress /y Q S <br /> City "CV St q'Zip"15�� Bus. Ph'L Q— aLgPh. <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,3he permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. / <br /> Signature_6�,�— Date 5 Z <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Nam <br /> Address J 5 r 1 C{ Bus. Phone w 2 <br /> City ( ZipOwnerlOperator Viad or <br /> �� <br /> Che k all appropriate services provided: <br /> wastewater disposal 121-compartment sink electrical hook-ups <br /> 0 Solid waste disposal Food preparation C�Toilet and handwashing <br /> iV'Hot & Cold water for cleaning ❑ St re refrigerated food ['Potable water <br /> Store dry food/supplies Overnight parking G4ehicle wash <br /> 1, ' 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 toly with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o sh otify HD' ediately. <br /> Signature <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 wwN.sjgov.org/ehd <br />