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JI' <br />SA R J OA Q U I N Environmental Health Department <br />COUNTY <br />r_+ <br />G no Mr <br />ess aor+s <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 <br />by <br />APPLICANT <br />Business Name_ <br />C H ap <br />c— S 1 W C d S <br />Lic. Plate # <br />Owner/Operator <br />PhQ0O 4Qo-iy1QAlt. <br />I,� � 7 , 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 penalties. g <br />12. To be completed by COMMISSARY OWNER/OPERATOR I <br />Commissary Name <br />Phone 7v — s'C / — I L <br />v <br />Check all appropriate services provided: <br />Wastewater disposal El,3-compartment sink <br />Cl/Solid waste disposal {" Food preparation <br />IYHot & Cold water for cleaning Store refrigerated food <br />O Electrical hook-ups <br />[Toilet and handwashing <br />ED/Potable water <br />pe!�tore dry food/supplies Ild Overnight parking Go'Vehicle wash <br />I, <br />RA:! I )o ly , 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. A f <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 />WWI <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 />