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' SAN 10AQ U I N Environmental Health Department <br /> --COU NTY---- <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 by APPLICANT <br /> // <br /> Business Name �Tll Lic. Plate# LAS L3 <br /> Owner/Operator Name 4 r1 dt <br /> Busine s Mailing Address _ l d L`l ej <br /> City Stated.&_Zip�S�7 Bus. Ph.-94 (Wo-611 It. Ph. <br /> I, , 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 (EHO) 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 ure ,an naltie . <br /> Signat - Zea Irl Z • Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryNamez _ �- <br /> FA# <br /> Address 41rca <br /> � I.4/rA Bus. Phone ?o —-5-L i — 1 V 6 6 <br /> City S�y G i<_✓I Zip Owner/Operator s c 11j,,, , J <br /> Check all appropriate services provided: <br /> X Wastewater disposal ef 3-compartment sink iZ Electrical hook-ups <br /> Solid waste disposal P Food preparation a Toilet and handwashing <br /> Hot& Cold water for cleaning M Store refrigerated food �t Potable water <br /> Store dry food/supplies Overnight parking rZVehicle wash <br /> I, t,4&:S 2.aZ V, r> . 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 notify the EHD immediately. <br /> Signature Date 4L47 <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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />