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SANtlOAQUIN Environmental Health Department <br /> COUNTY— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3- <br /> 1. <br /> .1_ To be completed by APPLICANT <br /> Business Name 4 U Lic.Plate <br /> Owner/Operator Name <br /> Business Mailing Address29 <br /> Cit�yip State6 Zip qS7d/0 Bus. h&X f–9/ '�7// Alt Ph. <br /> I, 4 S hereby state that the above information is current,.true and cornu to <br /> the best 6f 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 /> Signature�(� lT J Q \� Date <br /> 2.To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary <br /> Address CgOIW E ��CV_Av g J Bus. Phone `a� <br /> City �i�UC K�Cv� Zip SIS 205 Owner/Operator Ctn: �? A <-ne-A- <br /> Check all appropriate services provided:: <br /> .211�Wastewater disposal W3-compartment sink EI 'cal hook-ups <br /> /olid waste disposal E3 Food preparation T 'let and handwashing <br /> 0 Hot&Cold water for cleaning [3 Store refrigerated food ble water <br /> re dry food/supplies Overnight parking Vehicle wash <br /> 1, CUA F�A/19 �Z hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,an eets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the co ons of this agreement, or if this agreement is modified or cancelled, the <br /> commissary er shall notify the D immedia ` <br /> Signature �A sGG Date �/ ` <br /> 3. To com leted b the ENV H H 'urisdiction 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 952051 T 209 468-34201 F 209 464-0138 1 www_sjgov.org/ehd <br />