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SAN JOAQUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facilityi, 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 bAPPLICANT rr-- <br /> Business Name l� K T Lic. Plate# 9- <br /> Owner/Operator Name I G V­ a 2L_21/� <br /> Busine s Mail' g Address Ir(J <br /> City S L OStat Zip ff�ZI S Bus. PtOtl I 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.L <br /> Signature I/I G T a V S d. I r l Date I N 2j <br /> 2. To. be Completed by COMMISSARY OWNERIOPE#tATOR <br /> Commissary Nam <br /> Address 1 Bus. Phone 2 <br /> City L ZipOwner/Operator Va <br /> Che7k all appropriate services provided: <br /> astewater disposal Cr-3-compartment sink Er'6ectrical hook-ups <br /> E St�olid waste disposal Food preparation B -Toilet and handwashing <br /> E'Hot& Cold water for cleaning ❑ St re refrigerated food CrPotable water <br /> 0 Store dry food/supplies Overnight parking ❑Vehicle wash <br /> 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 ly with the conditions of this agreement, of if this agreement is modified or cancelled, the <br /> commissary ow sh otify HD ediately. <br /> Signature Atf Date <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 /> 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 />