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SAN JOAQUIN Environmental Health Department <br /> • ..._ ---c o u N Tyr-_.._. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility v Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be com feted by APPLICANT -7 <br /> Business Name P C o s � b')/1J-0S �S 1 e bFS Lic. Plate# S;JT P <br /> Owner/Operator Name ; 1 6✓y <br /> Business Mailing Address '2-S4 <br /> Cit x( ' P4--ectA State(IZip g1533_7 Bus. Ph. 2P4Q 0? 6t( 64' Alt. Ph. <br /> I,Vfk) bkE Z , 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 pfnalties. <br /> Signature 7,4el b4Lt Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> / <br /> Commissary Name I fo r i — 62 lf=r-t' i FA# <br /> Address 7 y c{ 0 S. kr(2O r-S- IVC,-, Bus. Phone c 4�-� <br /> City {--yr Zip q_7,J 6, Owner/Operator e d <br /> Check all appropriate services provided: <br /> L Wastewater disposal u)' 3-compartment sink ;V Electrical hook-ups <br /> Solid waste disposal Id Food preparation i Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food Wi Potable water <br /> 01 Store dry food/supplies Overnight parking T1 Vehicle wash <br /> I, e S 14 r U 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 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 /> RENS Signature Date <br /> 1868 E. Hazelton Avenue i Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />