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SAN��JOAQUIN Environmental Health Department <br />—COUNTY— <br />Greatness grows here. <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 />Owner/Operator <br />VIM <br />Citvy'' � State *�Zip 6oZQ3 Bus. Ph.ad9�Z/O— 3731, Alt. Ph. <br />I, A40'e L (3 P)M!Qa i bAT�z , hereby state that the above information is current, true and correct to <br />the best of my knowle ge 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 />2. To be completed by COMMISSARY OWNER/O <br />Commissary <br />e. <br />City , (.f/i- Zip Yb419S Owner/Operato <br />Check all appropriate services provide�d- <br />a/Wastewater disposal WS -compartment sink <br />fy Hoot <br />id waste disposal E3Food preparation <br />& Cold water for cleaning ❑ Store refrigerated food <br />f3 Electrical hook-ups <br />GY%ilet and handwashing <br />Er Potable water <br />❑ citgre dry food/ plies Overnight parking ❑ Vehicle wash <br />I. C 0,11/ V /ti b hereby state that the information I have provided is current, true and <br />correct to the be6t of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fa" comply with thep?iditions of this agreement, or if this agreement is modified or cancelled, the <br />commiss ow er shall notiify�HD immediate <br />Sinnnti� a ��1 A.e.,�.. ��1�/t�f��ri t� nates R —"o — ;P -O 3-/ <br />3. To be completed by the ENV HEALTH iurisdiction 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 />RENS 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 />