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SIGN JOAQUIN Environmentai HeaKh Department <br /> —COU NTY---- <br /> Greoh;ss. nF ;s here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility's 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 /> Business Name (Zt- i 4-70C., Ii04 4< Lic. Plate# I?1W <br /> Owner/Operator Name <br /> Business Mailing Address� j <br /> Citycr I se n State_{ Zip Bus. Ph. C- ' `- = r-''?a Alt. Ph. <br /> h _ <br /> I r 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. <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name �r "GL�w r`�SV FA# <br /> Address Bus. Phone /-Zrj% 7 N'ys4 <br /> City—/ zip J '—°I,' Owner/Operator <br /> Check all appropriate services provided: <br /> Er Nastewater disposal compartment sink D-Electrical hook-ups <br /> (olid westP disposal Food preparation toilet and handwashing <br /> El--16ot & Col water for cleaning ore refrigerated food O'1:5-otable water <br /> M-8-tore dry food/supplies overnight parking ra-rlehicle wash <br /> 1, . A 7 7Y,:e, , hereby state that the information I have provided is current,true and <br /> c6rre6f 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 /> SignatureDate Z Z <br /> 3. To be com feted by the ENV HEALTH jurisdiction 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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 i T 209 468-34201 F 209 464-0138 i www.sjgov.org/ehd <br /> s <br />