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SAN <JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> _ <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility . Caterer <br /> Complete sections land 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 I1/5 Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City /� State rAZipfl:�ZyKBus. Ph(;7.4`IJ -?ZZ—Aic�ZAIt. Ph. <br /> 6141441 hereby state that the above information is current, true and correct to <br /> the best of Ay 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 holdermust notify he EHD. Failure to notify this office may result in permit <br /> revocation and pen Itie . <br /> Signature Date / <br /> 2,;To be:com leted b ,CQWISSARY OWNEMPERATOR <br /> Commissary Name /FA# <br /> Address 6ZO 6- 10 NA-- Bus. Phone! 7o`t� ZZy� S3� i <br /> City LQ-UZ Zip 35 Z 91 Owner/Operatorr,�Ar�a- <br /> Check all appropriate services provided: <br /> m/�Vastewater disposal ®'3-compartment sink U"EEl/lectrical hook-ups <br /> Solid waste disposal preparation WT ilet and handwashing <br /> tore <br /> t& Cold water forcleaningt�F)od <br /> �ore refrigerated food Gd Potable water <br /> dry food/supplies WOvernight parking %N"'ehicle wash <br /> I, AZ4eZP - i sJwr , 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 owwn/nn_eff shall notify the EHD immediately. <br /> Signature / Date 44— <br /> wow <br /> -2Z <br /> . . _ _ San Joa uin 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 />