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`=" SANJOAQUINp, <br />Environmental Health De artment <br />—COU NTY— <br />Grrotness grows here. <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 leted bAPPLICANT U <br />Business Name ��� � \ (_�\ f) ��� 4` Lic. Plate# \�~� <br />Owner/Operator Name)w <br />J <br />Business Mailing Address ( t <br />Cityy tiC State G1Zip CL 3 (Bus.WIt. Ph.�° <br />\ 11 <br />Wereby state that the above information is current, true and correct to <br />the best of my knowledge anj agree to utilize my approved commissary in accordance with California Health & <br />Safety Code, and San Joaquin County Environmental Health Departmen' (EHD) requirements. If the use of the <br />commissary is discontinued, they permit holder must notify the EHD. Failure to notify this office may re suit in permit <br />revocation and penalties. iA <br />Signatu <br />-5I'4Iz2 <br />12. To be completed by COMMISSARY OWNER/OPERATOR I <br />Commissary <br />Check all appropriate services provided: <br />®' Wastewater disposal O 3 -compartment sink Electrical hook-ups <br />Solid waste disposal 0 Food preparation JZ! Toilet and handwashing <br />Hot & Cold water for cleaning O Store refrigerated food Pl-Potable water <br />(1 Store dry food/supplies ..Overnight parking 0 Vehicle wash <br />1, 144 �_ A) , hereby state that the information I have provided is current, true and <br />correct to fhe'15est 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 t'fy thg�EHD J ediately. <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 />9019 <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 />