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SAN J O A Q U I N Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o Caterer <br />Complete sections 1 and 2. It your commissary is located outside or San Joaquin County also complete section 3. <br />1. To <br />/V -c IS <br />Business <br />Owner/Operator <br />APPLICANT <br />ufS +h'F� 10 <br />Plate # <br />9 <br />Business Mailing Address`- q 3 y YWD/Vt7 C,L�t U / <br />CityC I, j") T j \/ State �f+ Zip a1` 09Bus. Ph.� °9 ALU 09 � Alt. Ph. <br />I, �t�/ I SYS C� 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 dis ntinued, th older must notify the EHD. Failure to notify this office may result in permit <br />revocation and pen (ties ) % <br />Signature nate 1�/ 2 / 2 ) <br />j2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name S -4Z C CA FA# <br />Address_CcW Bus. Phone(2A)2Z Lk—e33y <br />City ( 'Qk1 Zip OtS2�- ) Owner/Operator N60k N& o C -X V\o C1 <br />Check all appropriate services provided: <br />Ip Wastewater disposal 0 3 -compartment sink JZ Electrical hook-ups <br />Solid waste disposal ❑ Food preparation Toilet and handwashing <br />Hot & Cold water for cleaning V Store refrigerated food Potable water <br />❑ Store dry food/supplies q Overnight parking )3 Vehicle wash <br />I,(pMMkL' & (lS iii Z.�,et^U , 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 />Sign <br />Z I Z Ia <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. � <br />he commissary is located in County. The above food facility meets the <br />)mmissary requirements in California Health & Safety Code. The above checked services are available at the <br />tove commissary. Please notify EHD if the status of their operating permit changes. <br />HS Sign <br />38 E. Hazelton Avenue i Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www,sigov.orglehd <br />