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SAN 10AQUIN Environmental Health Department <br /> ---COUivTY-- <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 /> l� ; J <br /> Business Name «��; .s (-/I r'o Lie.Plate <br /> Owner/Operator Name _ Ej,;u;r dLa <br /> Business Mailing Address f -E7 ,/-�, <br /> City 56Li.t-4y - State C�>�Zip ci t ZiL Bus. Ph. d4 -1 i-Q TAlt, 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 (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 /> Signature — Date JSz�5��z� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> t � <br /> Commissary Name FA# <br /> Address , 2 <br /> GG ;' ,� 1 ' F[i� Bus. Phocneli�`4i/ <br /> L-1 Ll — S 7L' <br /> City i 1 Zip C S S Owner/Operator ey ( %z NCS <br /> Check all appropriate services provided: <br /> Wastewater disposal 11 3-compartment sink Electrical hook-ups <br /> Solid waste disposal [3Food preparation Toilet and handwashing <br /> I Hot & Cold water for cleaning ❑ Store refrigerated food Potable water <br /> ❑ ore dry food/suppliess , 1t Overnight parking Vehicle wash <br /> I' ( 4W/"� ICAA > 40e+ 7— , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, an meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the itions of this agreement, or if this agreement is modified or cancelled, the <br /> commissavner shall potify the HD immediately. <br /> Signature� ` `� �� L �� Date —S b -2 <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />