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- --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 /> Business Name EZL Lic. Plate# <br /> Owner/Operator Name C"o C'r� 1 <br /> Business Mailing Address I( `I " > r'j r <br /> CityrYacy State�Zip cls Bus. Ph. O� IO g52Arllt. Ph. <br /> hereby state that the above information is current, true and correct to <br /> the est of my knowie ge 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 I r" o Date <br /> 2 To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name to >tIPDrnra �l�. LCU'l� 5 Q I�j FA# <br /> Address Z q Sb S. A,(-12 C.,c= Bus. Phone <br /> City `)4cU v_Ii & Owner/Operator <br /> Check all appropriate services provided: <br /> _r&Mastewater disposal 1�3-compartment sink a'Electrical hook-ups <br /> Volid waste disposal 9' Food preparation •`''Toilet and handwashing <br /> E= Hot& Cold water for cleaning 5/Store refrigerated food Potable water <br /> 'Store <br /> ddry food/supplies Overnight parking i rrVehicle wash <br /> 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 /> Signature Date_ �� 2 <br /> 3. To be completed 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 1 T 209 468-3420 1 P 209 464-0138 1 www.sjgov.org/ehd <br />