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SAN JOAQUIN Environmental Health ©epartms t <br /> —--COU r\l T Y--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections f 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 ( SA/-2)/26 <S 6 Lic. Plate#?) Q l 1 <br /> Owner/Operator Name 7= P_( k-fl <br /> Business Mailing Address � &A LDA 5 -7 <br /> City 7�'k7)/utate (-'�ZipS c 'Bus. Ph. 0l- ?J1�/yU�It. Ph. <br /> I, !2/)Q6 , 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 lties. c <br /> Signature C< J Date z Z <br /> 2. To be completed//b COMMISSARY OWNER/OPERATOR <br /> Commissary Name l� lI qy/n 1 / 7� _r� Sti' 0� FA# <br /> Address -2-LIyy S. 4%CQf )1 / Wc,.y_ Bus. Phone ?U9 S / 1 <br /> City 51-0C-1c Zip c1� ZO& Owner/Operator RL�r� j; -obi c, <br /> Check all appropriate services provided: <br /> p'Wastewater disposal t9Z 3-compartment sink 4 lectrical hook-ups <br /> G(Solid waste disposal —/Food preparation Toilet and handwashing <br /> t-KHot& Cold water for cleaning � Store refrigerated food Potable water <br /> Store dry food/supplies G�Overnight parking r_-JVehicle wash <br /> I, ��1Q � C> , 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 /> SignatureI C � Date Lb 2 w <br /> 3. To be completed by the ENV HEALTH jurisdiction 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 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />