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SANJOAQUIN Environmental Health Department <br />—COUNTY -- <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. To be completed by APPLICANT <br />Business <br />Owner/Operator <br />Plate #_ 12-123C 2 - <br />Business <br />Business Mailing Address 1() 20 West OAi< Street , <br />CityS-tockton State-Cj�_Zip g52b3 Bus.Ph.aoq-(p`t2-3233 Alt. <br />I, (:2 J i I ler tYlo FuctlifA ) F2 , 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. q j� <br />12. To be completed by COMMISSARY OWNERLOPERATOR I <br />Commissary <br />Check all appropriate services provided: <br />;r' Wastewater disposal 1=1 3 -compartment sink <br />Solid waste disposal 0 Food preparation <br />!S� Hot & Cold water for cleaning i i Store refrigerated food <br />Electrical hook-ups <br />Toilet and handwashing <br />13 Potable water <br />E3 Store dry food/Supplies P- Overnight parking Vehicle wash <br />I, zta .pr IV , 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;wtify the�EHD i9;tnediately. <br />1 3. To be completed by the FAV HEALTH iurisdiction 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 <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 />