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°P SQNJOQQUIN Environmental Health Department <br /> Lsth�- —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 /> 1 . To be completed bAPPLICANT <br /> Business Name ( '%ncic� Lic. Plate# <br /> Owner/Operator Name Mjf_es4C4 2 <br /> Business Mailing Address ale.. <br /> City S&cy,tpn StateCA ZipcfS215 Bus. Ph.C.7Jc?Cj��KY,-7455 Alt. Phl2 5- 1(v�Z <br /> 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. /p, , ' " <br /> Signature �' Date 71-'/0 �LL <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name �rr� FA# <br /> S J7� Bus. Phone ��Dy��� Leks_' f <br /> Address / <br /> City L/rzl Zip Owner/Operator <br /> Check all appropriate services provided: <br /> R Wastewater disposal O 3-compartment sink Gr Electrical hook-ups <br /> g'Solid wastq disposal O Food preparation CrToilet and handwashing <br /> ff Hot & Cold water for cleaning O Store refrigerated food E Potable water <br /> 0 Store dry food/supplies I Overnight parking Ff Vehicle wash <br /> I, ' - 4AAeA , 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 comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall no 'fy the HD imrpediate ly. <br /> Signature / Date <br /> 3fiTo'be'oom leted by the'E 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 />