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SAN JOAQUIN Environmental Health Department <br /> —COUNTY — <br /> ° . Greotness grows here. <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 be completed by APPLICANT <br /> Business Name D0 2 Lic.Plate# <br /> Owner/Operator Name <br /> Business Mailing Address_ �^T l <br /> CityLlV1 ` n StatZip `j� P3 Bus. Ph. 'G()q WV� ry b� +lt. Ph. <br /> 1, 8&rCA t��I O��n 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 discontinued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a penalties. <br /> Signature (AJV v Date – 10 ^ �D 22 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ) �C t1, FA# <br /> Address :�r t I C� �R!Rus. Phone ,G- <br /> c <br /> city� ( Zip C(x Owner/Operator t <br /> Check all appropriate services provided: <br /> Wastewater disposal C+t'�3-compartment sink ❑ Electrical hook-ups <br /> Solid waste disposal -J Food preparation 3 Toilet and handwashing <br /> Ir Hot & Cold water for cleaning CK Store refrigerated food d Potable water <br /> )13�Store dry food/ upplies ❑ 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, 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 otifythe E immedi ely. <br /> 1yZ� <br /> Signature Date <br /> 3. To be com leted b the ENV HEALTH 'urisdetion outside of <br /> San-J-oaquin 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 /> A 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 />