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SAN ,JOAQUIN Environmental Health Department <br /> COU � r" <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 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 Lk- ;P AU pk 1 1 A Lic.Plate#7/l/X ?00�5 <br /> Owner/Operator Name <br /> Busies Mailin Address 2 <br /> City �2 Ow-tZAzip 90 Bus. Ph I Z 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 /> SignatureC�4 � Date <br /> 2. To be completed by COMMISSARY OWNERIOPERATOR <br /> i <br /> CommissaryNam bfim, t/I ( h <br /> Address r h l Bus. Phone � E <br /> City L ZipOwner/Operator Va 0 U <br /> Call appropriate services provid�ed� <br /> Wastewater disposal 0'3-compartment sink Cei"Electrical hook-ups <br /> lid waste disposal Food preparation 01"Toilet and handwashing <br /> 0 of&Cold water for cleaning ❑ St re refrigerated food t-Potable water <br /> Store dry food/supplies Overnight parking 04ehicle 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,9691y with the conditions of this agreement, a if this agreement is m dified r cancelled, the <br /> commissary ow sh otity t HD ' ediately. � 1 <br /> Signature f 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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wevw.sjgov.org/ehd <br />