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p b <br /> SAN JOAQUIN Environmental Health Department <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 / 5 —Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City State ('Ja Zip95z410 Bus. Ph��d'7 �/2_—/fl �AIt. Ph. <br /> I, �f ri®�i< llhi hereby state that the above information is current, true and correct to <br /> the best of y 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 penaltie . <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 4d.0' SAY Az'.1e-A FA# <br /> Address (OZO S ;SliGY r t® sk Bus. Phone ��g? ZZ-9- 835y <br /> City Gv of Zip q5 Z V Owner/Operator &9kddjn+— /•IGLrti— <br /> Check all appropriate services provided: <br /> m/(Nastewater disposal U'3-compartment sink U EEl/lectrical hook-ups <br /> olid waste disposal /Fpod preparation �C'T filet and handwashing <br /> l <br /> ore <br /> & Cold water for cleaning m Store refrigerated food Cd Potable water <br /> Store dry food/supplies [/Overnight parking %4ehicle wash <br /> I, h4tz4-- 6w4p-^-3JcVY , 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 owne ll notify the EHD immediately. <br /> Sign; ture�T Date /'0' ZlJ�ti'Z_ <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 />