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s pooh <br />SAN JOAQUIN <br />Environmental Health Department <br />—COUNTY <br />Greotness 9roV, <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 I <br />Business Name 5''C%,\c i LL -L Lic.Plate# <br />Owner/Operator <br />Business Mailing <br />City 'LM State(LA I15' 242 Bus. Ph.ge� 1- i-1 bL13( Alt. Ph. <br />I,A hA i 0 A4 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. )/ <br />2. To be completed by COMMISSARY OWNER/OPERATOR I <br />Commissary Name ISLE <br />City <br />Check all appropriate services provided: <br />p Wastewater disposal 0 3 -compartment sink O Electrical hook-ups <br />a Solid waste disposal 0 Food preparation -b. TdTlet and handwashing <br />p Hot & Cold water for cleaning -0 Store refrigerated food 19 Potable water <br />C9. Store dry food/supplies B- Overnight parking O Vehicle wash <br />1, Ifi L1� l In nL4L- , hereby state that the information I have provided is current, true and <br />correct to the best of my know) dge, 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 owne all notify the EHD mediately. 1 <br />Signature Date <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 Sig <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 />