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SAW JQAQUIN 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 /> 'i_ To,be cornleted by APPLICANT 1 <br /> Business Name <br /> Lic.Plate#�`J~�� <br /> Owner/Operator Name <br /> Business ili g Address <br /> City�y f State�Zip 97 Bus. 7/AIt Ph. <br /> hereby state that the above information is cunenk true and carred 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 <br /> 12- To be qoMpldted-by COMMISSARY OlVNER(OPERATOR <br /> Commissary Name LA FA# <br /> Address_aQj_E. k(N. ,,4 uk Bus. Phone Soci• nLj <br /> City Zip 05 1.05 OwnerlOperator <br /> Check all appropriate services provided: <br /> & Wastewater disposal &3-compartrnent sink cal hook-ups <br /> (olid waste disposal Food preparation �T "Iet and handwashing <br /> Hot&Cold water for cleaning ® Store refiigerated food fi<: P ble water <br /> M S pa dry foodlsu lies WOvemight parking - Vehicle wash <br /> 0 <br /> hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the Cal'rfomia Health&Safety Code requirements. if the food facility <br /> operator fails omply with the condfi ^of this agreement, or if this agreement is modified or cancelled, the <br /> commisse owner shall notify the EIIVnmediately. / <br /> Signature �� ��� Date <br /> 3, To be completed by the ENV.HEALTH iEALTH 'urisdiction ouidef; aaJriCtSo <br /> The <br /> 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 46834201 F 209 464-0138 1 www.sjgov_orglehd <br />