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SAN JOAQUIN Environmental Health Department <br /> COUNTY- - <br /> { " Greatness grows h,71- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> i <br /> Business Nametc. Plate# <br /> Owner/Operator Nam SPCA-1 I-e. CF` r'4 f,ir)Ct S <br /> Business Mailing Address SA <br /> - <br /> City 1t)C_CC.00(j Stat�_zip 9.5�3 3 Bus. P S4 Alt. Ph. &/ v-a ql <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 permi ender must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. q �] <br /> Signature Date(�5 -D /- O <br /> 2. To be completed by COMMISSARY OWN/ER/OPERATOR <br /> Commissary Name Z r (t0 d FA# <br /> Address / Bus. Phone <br /> city. /d a zip�Owner/Operator f<ihru/r, l�e/,) <br /> Check all appropriate services provided: <br /> [,Wastewater disposal ❑ 3-compartment sink II'Electrical hook-ups <br /> Er Solid waste disposal ❑ Food preparation WToilet and handwashing <br /> a Hot & Cold water for cleaning 0 Store refrigerated food 'El' Potable water <br /> ❑ Store dry food/supplies Overnight parking V Vehicle wash <br /> I, 414 /%�a& , hereby state that the information I have provided is current,true and <br /> corr�to the best of m nowledge,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 shal otify e E immediately. <br /> Signature Date <br /> 3. To be completed by UM 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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />