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�- SQ N�� OQQ U I N Environmental Health Department <br /> Wk. ----COUNTY---- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 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 NamLia Plate# �'j�S q,� y,3 <br /> Owner/Operator Name 4k r yf�t L <br /> Busine(s} Ma/fling Address_ (c 3/v011 <br /> g �1 v�'aGlJ2G/ � 9 <br /> City _ State 6tZip /SG�6� Bus. Ph.,geY -/a-V- )359 Alt. Ph. <br /> I, '50�A e_ 4 L Na t2. hereby state that the above information is current, true and correct to <br /> the bet 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 <br /> 7- <br /> 2. To be com leted COMMISSARY OWNER/OPERATOR <br /> r , <br /> Commissary Nam i FA# <br /> Address 'WD 1 Gti4s� Q Bus. Phoneo��/� (O - 1f <br /> City Zip a L Owner/Operator guy ZQ <br /> Check all appropriate services provided: <br /> [� Wastewater disposal 6 3-compartment sink tbI Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation ! Toilet and handwashing <br /> Hot& Cold water for cleaning ❑ Store refrigerated food Potable water <br /> or dry food/s lies Overnight parking Vehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge,an meets the California Health&Safety Code requirements. If the food facility <br /> operator fails comply with the ditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ownp shall notify the HD immediate) - r <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa , uin;Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Cade. 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />