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,�oy,Quu.. •.. <br />lQ r� <br />SANJOAQUIN Environmental Health Department <br />COUNTY— <br />Greatness 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 />W. -To be completed by APPLICANT- <br />1�� ��� p <br />Business Name W � Lic. Plate # p <br />Owner/Operator Name �� ��r���ii Q <br />Business Mailing <br />- 1 I T I Alt. Ph <br />I, , hereby state that the above information is current, true and correct to <br />the be t of my knowled a 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 discontiqued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penaltit#. n t <br />Signature. <br />IIA <br />. To be completed by COMMISSARY OWNER/OPERATOR <br />Check all appropriate services provided <br />Phone(ZM) 214 -$3 3`i <br />z <br />gL Wastewater disposal `6(3 -compartment sink -W Electrical hook-ups <br />Pt Solid waste disposal 0 Food preparation I, Toilet and handwashing <br />$4 Hot 8r Cold water for cleaning 9 Store refrigerated food IN Potable water <br />1p Store dry food/supplies 1% Overnight parking la Vehicle wash <br />I, A�2ke m , hereby state that the information I have provided is current, true and <br />correct to the best ofrAy 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. I t <br />Signature <br />[1J <br />13. To be corn6letecf 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 />REHS Sig <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 />