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SANJQAQUIN Environmental Health Department <br />—COUNTY— <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 />11. To be completed by APPLICANT <br />Business Name , 6'ec j -12S a -�� le S2vu \'0--n.. �- L C Lic. Plate # 8T L r5? q8 <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 />Commissary Name She,- Pef IS&k FA# 00030-7/ <br />Check all appropriate services provided: <br />p Wastewater disposal M3 -compartment sink <br />E3 Solid waste disposal <br />PS Hot & Cold water for cleaning <br />A Food preparation <br />2 Store refrigerated food <br />Phone 205 8'3i 2 2 Sy <br />r �cx zvcr�� �rl �g <br />Electrical hook-ups <br />$[ Toilet and handwashing <br />A Potable water <br />d.. Store dry food/supplies// � WOvernight parking ti -Vehicle wash <br />1, �g .�/rN-/4101-Z �! A6.,< 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 wit f conditions of this agreement, or If this agreement is modified or cancelled, the <br />commissary ow�f��,ir{(��hall notify EHD i ediately. <br />Signature .U/ Date <br />1 3. To be comDleted by the ENV HEALTH iunsdiction outside of San Joaauin Co. I <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 />