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SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> Greotness grows here. <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 /> Business Name fL✓t S :" U Q✓ A Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City State—Zip Bus. Ph. Alt. 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 <br /> 2. To be com leted b . COMMISSARY OWNER/OPERATOR <br /> Commissary Name 474z!EriL YJ FA# <br /> Address 6,7e) =GcCr<c Y'> _f Bus. Phone <br /> City 2_&V r ' Zip ci 5-7 re Owner/Operator <br /> Check all appropriate services provided: <br /> [p1'/�Vastewater disposal compartment sink mElectrical hook-ups <br /> 0 olid waste disposal �Food preparation 13 Tgilet and handwashing <br /> CVsHot & Cold water for cleaning WStore refrigerated food M Potable water <br /> O/tore dry food/supplies l7/116vernight parking U—T/Vehicle wash <br /> I, *L , 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 <br /> ,&I To be completed b the�ENV HEALTH 'urisdiction outside of San J,oa uin 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 />