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°U SAN JOAQUIN <br /> ,-_ Environmental Health Department <br /> —COU NTY--- <br /> 'cgc,coa��4" Greatness grows hE-e- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 1 and 2. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT �t <br /> Business Name Lic.Plate# <br /> Owner/Operator Name (k <br /> Business"Mailing Address I U ( ��1 S\- <br /> City Sti�Ck Y� State LQ Zip SZ-6o Bus. Ph. 2��A .,I 1y L �S Alt. Ph. NO gjZ0I aT- <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 un En ironme tal Health Department (EHD) requirements. If the use of the <br /> commissa i disco inued,the ermit hol r mus notify the EHD. Failure to notify this office may result in permit <br /> revocation n anal s. <br /> Signature I Cl Date Z 2Z <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name�r)�i�r C // l�� FA# <br /> Address // //7� ) �p� h�PfT/�l �� Bus. Phone 9 <br /> City &YJ Zip wner/Operator <br /> Check all appropriate services provided: <br /> %r Wastewater disposal O 3-compartment sink IX Electrical hook-ups <br /> jr Solid waste disposal 6 Food preparation %T Toilet and handwashing <br /> l;r Hot & Cold water for cleaning O Store refrigerated food ErPotable water <br /> O Store dry foosupplies Overnight parking Ig Vehicle wash <br /> I, _, hereby state that the information I have provided is current,true and <br /> correct to the best of my knf ee ,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 no a E imp tely. <br /> Signature Date <br /> 3. To be completed by the E44V 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 />