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PROCI F363 <br />SAN JOAQUIN Environmental Health Department <br />—COJNTY --- <br />Greatness gr^w5 . ..-.. - <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 />11. T o be cornp/lyet�CIv t edby ApP�PLICANT <br />Business Name � �) L > R t 7E Lic. Plate# <br />Owner/Operator Name <br />Business ailin Address AU Y \ <br />City Staternzip �S Bus. Pha 1 G TJ 1 Alt. Ph. <br />I, ��_�� 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 JoaquinCo ty Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinued, th6 pe Ider 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 Nam d U�� f �l l VtAi_ ( � <br />Address M 6� Bus. Phone <br />city- <br />zipOwner/Operator <br />Check all appropriate services provided: <br />0 -Wastewater disposal Cr 3 -compartment sink Cd Electrical hook-ups <br />_Solid waste disposal Good preparation C Toilet and handwashing <br />la—Hot/& Cold water for cleaning C�IStore refrigerated food Ct"Potable water <br />H Store dry food/supplies O Overnight parking 13'�Vehicle wash <br />I, 1\/ , 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 comp) with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissaryno ner sh notify the EHD immedAtely. 1 <br />Signature III I - �'1/WI I A/I YAC 0 �iii� nate � l � i I 'Z' I <br />3. To be complete&by the ENV HEALTHjurisdiction outside d San Joaquin C®. <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 />N <br />