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A <br />SAN JOAQUIN Environmental Health Department <br />—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, com feted b .APPLICANT,. <br />Business <br />Lic.Plate# <br />Owner/Operator <br />Business <br />'Mailing Address I/Z �fri2%L/T G <br />City S �" W State�Zip X10 Bus. Ph. 2CF( - 59 -9 V 19Alt. Ph. <br />I, d -LD) f fi VrOA , 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 C untyEnvironmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, the rmitust notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature Date G)/0.3 <br />2. To be com feted b COMMISSARY OWNER?OPERATOR <br />City I `\ Zip q�2`'kO Owner/Operator N1.�\�O <br />C{ <br />Check all appropriate services provided: A <br />ty Wastewater disposal g 3 -compartment sink A Electrical hook-ups <br />Solid waste disposal $Food preparation ,I!�Toilet and handwashing <br />Hot & Cold water for cleaning `All Store refrigerated food A, Potable water <br />(Store dry food/supplies /D.Overnight parking vehicle wash <br />I, l)m(k, U %Z—,k—e( , hereby state that the information I have provided is current, true and <br />correct to the best of m owledge, 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 ownershall notify the EHD immediately. <br />Signatu <br />Z <br />3. To be,.com feted 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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www,sjgov.org/ehd <br />