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SAN J0AQUIN Environmental Health Department <br />—COUNTY -- <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 />r ^ j <br />Business Name -C r - Lic. Plate # L2- <br />Owner/Operator <br />Business <br />ic�r16,[elid<<I�tiT��1�=-�=+•�r�/Lr[; <br />1, l /" - , 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 penaIt Q <br />Signature I i/t/t t Q�(n ` CrI Date V <br />Call appropriate services provided: <br />Wastewater disposal W -3 -compartment sink L-?'�E-Jectrical hook-ups <br />� olid waste disposal Food preparation 2�Toilet and handwashing <br />Crlis�ot & Cold water for cleaning MSt re refrigerated food U� P�otable water <br />Store dry food/supplies Overnight parking U, -VI icle 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 tof,691y with the conditions of this agreement, o if this agreement is modified or cancelled, the <br />commissary o s/h/notify tHD" ediately. q <br />c:,...,....., !/ �i�--� r/� / <br />'3. To be completed by .the ENV HEALTH jurisdiction outside of San Joa uin Coy' <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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 mvw.sjgov.orglehd <br />