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T SAN-JQAQQIEnvironmental Health Department <br /> ' 41110 - —COUNTY— <br /> dw <br /> ,.., , ... .:. _;�t;:s '... .... ..: .. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility* 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 by APPLICANT <br /> Business Name i ic.PI e# <br /> Owner/Operator Name <br /> Business Mailing Address.29/1 <br /> CitZ� State(Al ip 2L07 Bus. Ph,:5ROj'– L/6/-°7d9%Alt. Ph. <br /> I, ktl IUD Jo Ill , 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 and penalties. <br /> Signatur Date <br /> F2—. To b am leted by COMMISSARY OWNER/OPERATOR .. <br /> Commissary Name l.. A Cm en c c.% A FA# <br /> Address q0100 E rxrk g vas, Bus. Phone on4C41 <br /> city �kU r Okunzip �S Zo6 Owner/Operator AErle t <br /> Check all appropriate services provided: <br /> I�Wastewater disposal 2/3-compartment sink 5eEla' cal hook-ups <br /> 13 Solid waste disposal M Food preparation T ilet and handwashing <br /> i6ot&Cold water for cleaning ® St refrigerated food ��table water <br /> 13 St dry foodisup lies / vemight parldng Vehicle wash <br /> I, /).. state that the information I have provided is current,true and <br /> correct to the bes f my knowledge,and he California Health&Safety Code requirements. if the food facility <br /> operator fail ocoply with the s of this agreement, or if this agreement is modified or cancelled, the <br /> commissa owne shall notify imniscriately, <br /> Signatu GGGC Date�--2 aa0 <br /> 3. To be com let d 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 952051 T 209 468-34201 F 209 464-0138 1 www.sjgov_orglehd <br />