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PPo"Yj-� o® [0 <br /> FA 2 (P <br /> SAN I]OAQUIN Environmental Health department <br /> COUNTY- - <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility w 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 (b APPLICANT o II� r <br /> Business Name T &r 1 i S ft 6c.Plate# t� 0{ -L_ <br /> Owner/Operator Name�M A rA -Fp-m 5 3t- <br /> Business Mailing Address �T <br /> City cf-k r\State04-ZipCfL)_0f0Bus. Ph6IAlt. Ph. <br /> 1, /✓�� hereby state that the above information is current,true and correct to <br /> the besi 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 V penalties. t / <br /> Signature (� CL �L sA�i/lQ�. Date b S Z <br /> 2. To be com leted b COMMISSARY OWNERIOPERATOR <br /> �� S <br /> Commissary Nam t� <br /> Address r h 1 Bus, Phone Z 1 HT1 <br /> City ( ZipqN (2) _Owner/Operator Va C) mf v <br /> Ch k all appropriate services provided:Wastewater disposal U'3-compartment sink Electrical hook-ups <br /> 0--solid waste disposal Food preparation B Toilet and handwashing <br /> C <br /> -Hot& Cold water for cleaning O0St re refrigerated food U-Potable water <br /> Store dry food/supplies Overnight parking U4ehicle 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 to ly with the conditions of this agreement, o if this agreement is modified or cancelled, the <br /> commissary ow sh I otity HD' ed+ately. <br /> Signature L �rihl/ Date <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 />