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SAN J AQUIN Environmental Health Department <br /> --COU NTY----- <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 I <br /> Business Name YA T �t l Lie. Plate# ( q <br /> �'; /^ <br /> Owner/Operator Name O G GY t; <br /> Business Mailing Address Qt 1 <br /> Cit :11—IrCAQ_StateCkZ1p qf- Bus. Ph. I d 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 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 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name�C n ,. r in 9 24V0 _FA# <br /> Address ?4M Z 'f Bus. Phone /165 <br /> City S:6C&,WA Zip 5-,7-0 iS Owner/Operator <br /> V <br /> Check all appropriate services provided: <br /> ® Wastewater disposal K 3-compartment sink W Electrical hook-ups <br /> 7[ Solid waste disposal -9 Food preparation Toilet and handwashing <br /> 14 Hot& Cold water for cleaning )0 Store refrigerated food Potable water <br /> Store dry food/supplies 14 Overnight parking Xr Vehicle wash <br /> I, �! ,"'—.s' y, 1 O , hereby state that the information I have provided is current, true and <br /> correct to a 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 <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 /> REHS Signature Date <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 />