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SAN JOAQUIN Environmental Health Department <br />COUNTY <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 />r( �II,, 22 <br />Business Name IOnC++�2� l,T'O2� 551_7 <br />Lic.Plate# ID <br />Owner/Operator Name (tvzA t moi+ 6LCrL�s�U <br />Business Mailing Address Si <br />City S1i, X-70`" StateCAL zip Bus. Ph.'ZC", - 9ad SSS -4 It. Ph. <br />I, 'L,Ac )2„a L�-\lcr-+cti 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 />\ LH -c2_ <br />Check all appropriate services provided: <br />a - Wastewater disposal <br />olid waste disposal <br />0_ 33 -compartment sink <br />E Food preparation <br />i <br />.CrHot & Cold water for cleaning Q/Store refrigerated food <br />Z�Store dry food/supplies E Overnight parking <br />ID lectrical hook-ups <br />Toilet and handwashing <br />X! Potable water <br />E Vehicle 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 to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />shall p�"e EHD immediately. CAI 1(2 I T/ <br />L I!I NY \ 6Vl/ (�/ln-\ Hata <br />3. To be completed by the ENV HEALTH `udsdiction 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 />V40EM <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 />