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SAN. JOAOUIN EnvlronnTaMaa leafth ©epaar�tmen <br />-- COUNTY --- <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 by APPLICANT <br />Business Name A LPx 8bQ Lic.Plate# <br />Owner/Operator <br />Business Mailing Address 22 S • VJA�V YL A+t° <br />City il111 %Q✓ ate �Zip S 2f 5 Bus. Ph ? Ucj%{'S' Alt. Ph. <br />I, n✓ ( ,lam'= hereby state that the above information is current, true and correct to <br />the b t of my knowledge and agree to utilize my approved commissary in accordance with Califomia Health & <br />Safetyf Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discgnti%ued, ty% pemfij hold ust notify the EHD. Failure to notify this office may result in permit <br />revocation and o es. <br />Comm <br />Commissary <br />City ( T) ( Zips 11 Owner/Operat <br />Check all appropriate services provided: <br />Wastewater disposal 3 -compartment sink <br />Solid waste disposal p Food preparation <br />Hot & Cold water for cleaning ' Store refrigerated food <br />Edi Store dry food/supplies 13 Overnight parking <br />20Z_J <br />Phone <br />or ) f <br />12 Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />® 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 comply with the conft#'s of this weement, or if this agreement is modified or cancelled, the <br />commissary owner shall notifyffie EHD mmediate <br />13. 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 <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 />