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SANJOAQUIN Environmental Health Department <br />- -COUNTY <br />— <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o 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 com leted fs PLIG/ PiT 9 <br />Business Name JA(46 f Lic. Plate# <br />Owner/Operator <br />Businesp Mailing Address I/Aff <br />City Statej�+ ZipS�Bus. Ph,�P2-(fSS &gP3Aitt Ph. <br />I, C q S / ( o hereby state that the above information is current, true and correct to <br />the best df my knowledge and aree to utilize my approved commissary in accordance with California Health & <br />Safety Code, a an 'oaquiunty Enviro a thl Ith Department (EHD) requirements. If the use of the <br />commissary i discontt ued the i holder u� n e EHD. Failure to notify this office may result in permit <br />revocation a d pennaalties. / <br />Siqnature t ( c I i Lit Date <br />12. To be completed by COMMISSARY ADWNERIOPERATOR <br />Commissary Name I_ A Cc) (Ap Cc FA# <br />Address OPW 'L "CV_A, ,,4yAh Bus. Phone <br />City � �U {on Zip 615 Zo 5 Owner/Operator_ ,A <-n e t - <br />Check all appropriate services provided: <br />21*�Wastewater disposal <br />V/3 -compartment sink <br />waste disposal <br />Food preparation <br />/olid <br />d Hot & Cold water for cleaning <br />® Store refrigerated food <br />�,Store dry <br />correct to the b of my knowledge, and <br />operator fail o ompty with the Gond <br />commissa o"r shall notify theI jD <br />Ovemight parking <br />0'--E I 'cal hook-ups <br />T 'let and handwashing <br />bie water <br />Vehicle wash <br />hereby state that the information I have provided is current, true and <br />m the California Health & Safety Code requirements. If the food facility <br />s of this agreement, or if this agreement is modified or cancelled, the <br />E immecriately. ;_ <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 />1.10IN <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www_sjgov_org/ehd <br />