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SAKJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> .-,. v, tic <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 C ic.Plate#!a <br /> Owner/Operator Name 1 <br /> Busine Mailing Address <br /> City I StatefAZA-<QX2E--Bus. Pha Alt. Ph. <br /> 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 /> Signature Date <br /> —III fo <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Nam l� <br /> Address r'b (1 f1 I Bus. Phone w 1 7� <br /> City (, zipOwner/Operator Va C) f v <br /> Che7k all appropriate services provided: <br /> astewater disposal CF 3-compartment sink electrical hook-ups <br /> g0�-wSt�olid waste disposal Food preparation @'Toilet and handwashing <br /> id'Hot& Cold water for cleaning 0 St re refrigerated food UPotable water <br /> Store dry food/supplies Ovemight parking aVehicle wash <br /> I, 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 tofy with the conditions of this agreement, ent is modified or cancelled, the <br /> commissary o s otity HD' ediately. o if this agreem �/► � <br /> Signatures �CiA(il/ Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San 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 /> 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 />