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SAN JOAQUIN 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 <br /> Business Name771`3,Yk C c S � 1201„ I,-o S ( -e,S 1 ebFs Lic. Plate# <br /> Owner/Operator Name 16.Y F-0 (V fL el P i`t i7& Z <br /> Business Mailing Address 2S 4 Q f`t� 9 V <br /> Ci <br /> State.�.AZip c/com-337 Bus. Ph.2 ? 026'( 65' Alt. Ph. <br /> I,( ' bkE L 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 an p nalltiie�s. <br /> Signature 6�2Z Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> / FA# <br /> Commissary Name r n �.�- <br /> Address 7- V V V S. k r p,)r+ I .rum Bus. Phone 7�u 0 �- <br /> city Zip a!�ZJ 6- Ownerloperator S R:L <br /> Check all appropriate services provided: <br /> N, Wastewater disposal 3-compartment sink a Electrical hook-ups <br /> Ok Solid waste disposal Id Food preparation d Toilet and handwashing <br /> E4 Hot& Cold water for cleaning 10 Store refrigerated food 4 Potable water <br /> Q Store dry food/supplies Overnight parking T. Vehicle wash <br /> I, J±� eS f�Zu�9 ry , 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 Date_L4/ <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 />