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SAN JO QUI Env!ren mean- file Hc L'Ih, <br /> CC U f,,J T Y----- <br /> COMMISSARY <br /> -----COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 9 and 2. if your commissary is located outside of Sari Joaquin County also complete section 3. <br /> �. �o be com leted b APPLICANT <br /> Business Name 1, � 4 g i Com _ k_ic. Plate#_ i 7 <br /> Owner/Operator Name - - . <br /> Business Mailing Address <br /> City. l State 04� Zip 1 b7C?(0Bus. Ph.2 0 2 _4-y 2 S 6 Alt. Ph. <br /> I. 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. f <br /> Signature ` `���_ Date_ <br /> . To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary NameLAFj1rnPA# <br /> Address L) e "_r 6V . � Bus. Phone �:c � � y lit 4 L- <br /> City G L.6 a Zip T S 7_o •Owner/Operator e -, <br /> Check all appropriate services provided: <br /> -�/VVastewater disposal 1=2�3-compartment sink G�Electricai hook-Ups <br /> [Y Solid waste disposal K?Food preparation nn/Toilet and handwashing <br /> QXHot & Cold water for cleaning Store refrigerated food Potable water <br /> E�! Store dry food/supplies Overnight parking R`r'Vehicle wash <br /> 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 /> commissary owner shall notify the EHD immediately. <br /> Signature Date V Sr ]f <br /> . To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Go. <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 /> 1568 E. Hazelton Avenue i Stockton, California 95205 i T 209 468-3420 1 F 209 464-0138 j www.sjgov.org/ehd <br /> S <br />