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SANINAOUIN 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 /> 1. To completed-by completed-byAPPLICANT <br /> Business Name OA Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City d – State-Zip SdO� . Bus. Ph 0 - "e , 1-/0 Alt. Ph. <br /> 1 Gilt ! / /a , hereby state that the above information is current,true and correct to <br /> the best/of my knowled a 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 /> Signature4 1':ifL_ c4 Date_ <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> u <br /> Commissary Name/ Gl FA# <br /> Address a%(> ail s Bus. Phoned)O%�- qt-y ` ys ?D <br /> City 04; ' 9- Zip SaDS Owner/Operator_ <br /> Check all appropriate services provided: <br /> Ij wastewater disposal M 3-compartment sink Electrical hook-ups <br /> M Solid waste disposal ❑ Food preparation EJ Toilet and handwashing <br /> Hot & Cold water for cleaning ❑ Store refrigerated food Elf Potable water <br /> / Ftgre dry fo9gitsuppliiees � Overnight parking Vehicle wash <br /> ,,L oA l / L RN M/Gz , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, d meets the California Health&Safety Code requirements. If the food facility <br /> operator fails51-iva <br /> mply with the itions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa oshall notify EHD immediately. <br /> Signature <br /> 3. TO coni _;feted-�% the€fVU HEALTFI,'urisdi06h gtttside l<Sar }a- uin Ca <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />