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SAW 11GAUHN <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 9. <br />9. To be completed by APPLICANT <br />Business Name Lic. Plate # C0 <br />Owner/Operator Name <br />Business Mailing <br />ph W,=p(0 7'5 Alt. Ph. <br />1 �'4 a I(1 (� i � hereby state that the above information is current, true and correct to <br />the Nest 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. <br />2. To be completed by COMMISSARY OWNER/OPERATOR i <br />r�nm MiQQ=M1 <br />�=3 <br />Check all appropriate services provided: <br />6 Wastewater disposal 01- compartment sink G'Electrical hook-ups <br />[Solid waste disposal Food preparation i✓Toilet and handwashing <br />c��Hot &Cold water for cleaning /Store refrigerated food 'yPotable water <br />Se dry food/supplies Q Overnight parking Vehicle wash <br />fLzy 1 �0 t J _, 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 sh�all�tlfi/ EHD immediately. <br />et --- .. ­ <�___ i nate a 1 V 1 t.�—/Z' I <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 952051 T 209 468-3420 1 E 209 464-0138 1 wvvw,sjgov.org/ehd <br />