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SAN 10AQUIN Environmental Health Department <br /> —COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 /> Business Name G /0 Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address 2 9/7c /f2��2ot `Gt <br /> City & State, (?A Zip g(2 Bus. Ph.2,� 6 99 X1116 Alt. Ph. <br /> I, fyrwx fry 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 penaltie / <br /> Signature A—I,/1 Date "(/� <br /> l q l <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> r , <br /> Commissary Nam IlA# <br /> Address ' T Bus. Phon / <br /> City Zip Owner/Operato f <br /> Check all appropriate services provided: <br /> WVVastewater disposal E> -compartment sink M-Electrical hook-ups <br /> olid waste disposal ;VFbod preparation (2/Toilet oilet and handwashing <br /> lot old water for cleaning E�S ore refrigerated food l,3'Potable water <br /> Store dry food/supplies vernight parking C/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 o is agreement, or if this agreement is modified or cancelled, the <br /> commissary o ner shat otify the EHD imme is ely. , 1 / <br /> Signature k' 1� v Date V <br /> 3..To be completed 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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />