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SAN JOAQUIN <br /> a , Environmental Health Department <br /> ---COUNTY--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1_ To be completed by APPLICANT <br /> ��lT y� <br /> Business Name l/J <br /> / J Q� ` .) Lic_Plate# �"'VV 22 �' I <br /> Owner/Operator Name Y' T �rv �fIT' <br /> Business Mailing Address 3 �/ J C V11 J <br /> City ( (q(_C `j StateC�.Zip us. Ph 0" 7-9 -C ii jA t. Ph. <br /> 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 penal 'e'es. <br /> Signaiure /"'/� 'V /l f �/V t y Date n <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR c� <br /> Commissary Name o ll �` FA# 5 T t!D <br /> Address ���� C)�'P w1n C 7� Bus. Phone ZU` -�si�l�- ��r`/CO <br /> Cityl. cc C: Zip TOwner/Operator <br /> Check all appropriate services provided: <br /> ,V Wastewater disposal AJ 3-compartment sink 10 Electrical hook-ups <br /> ,Solid waste disposal H Food preparation JU Toilet and handwashing <br /> ,f Hot & Cold water for cleaning ZI Store refrigerated food fFf Potable water <br /> ,ice Store dry food/supplies a Overnight parking M Vehicle wash <br /> 1,— r , 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 � -/ Q � Date �7 1() <br /> 3. To be completed by the 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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />