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SANJOAQUIN Environmental Health Department <br /> — <br /> -COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility or Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 Tobe t'om feted by APPLICANT <br /> Business ame Lic. Plate# <br /> Owner/Operator Name I Ici -2-- <br /> Bus' ess Mailing Address f� 4,0o <br /> ( �v <br /> Cit yS/�Y$tate_ i Z� Bus. Ph7 2,q'� Alt. Ph. <br /> 1, ,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 penaltie r1 ) <br /> Signature - Date 1 v/ <br /> 2. To be com6let6d by COMMISSARY OWNER/OPERATOR <br /> Commissary Nam �� S <br /> Address �J Bus. Phone L nc <br /> City L Zip S� Owner/Operator VUt o W ID <br /> Che all appropriate services provided:: <br /> /Wastewater disposal 0--3-compartment sink electrical hook-ups <br /> 3 Solid waste disposal Food preparation O�Toilet and handwashing <br /> 12-Hot &Cold water for cleaning 0St re refrigerated food O'P�otable water <br /> Store dry food/supplies Overmight parking le' 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 to ly with the conditions of this agreement, of if this agreement is modified or cancelled, the <br /> commissaryow sh oti HD'r ediatel <br /> fy y. <br /> Signature i1 Date , <br /> 3.. Fbs:' tie EPk�t# EALTH;' risdicttt outside of.San Joh''ul►a;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 209 468-3420 1 F 209 464-0138 1 wwwsjgov.orglehd <br />