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SANJOAQUIN Environmental Health Department <br /> --COUN i Y-- <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 r <br /> Business Name K7r ) 5 fe Lic.Plate# <br /> Owner/Operator Name -T(t- Q 11 Cll <br /> Business Mailing Address / > <br /> City\Statr�Zip 6Bus. P Z Alt. Ph. <br /> I, ,hereby state that the above information is current,true and correct to <br /> the beq 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 /> Signature IfJLu0. S�i/1Q�1. Date S <br /> 2. To be Cam leted bY COMMISSARY OWNER/OPERATOR II^^ <br /> Commissary Nam �� 4 <br /> Address h 1 Bus. Phone 2 1 <br /> City ? L Zip OwnerlOperator VGt D 1 v <br /> Ck all appropriate services provided: <br /> Wastewater disposal �'3 compartment sink D"Llectricai hook-ups <br /> g Ss�olid waste disposal Food preparation 0- -Toilet and handwashing <br /> lrHot&Cold water for cleaning O St re refrigerated food l-Potable water <br /> Store dry food/supplies Ovemigh6 arking ehicle 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 ;;69ly with the conditions of this agreement, o if;DTate <br /> ent is modified or cancelled, the <br /> commissary o sh otiiy HO' ediately. <br /> Signature .� y� � <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, Califomia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />