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SANJOAQUIN 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 /> Business Name �1' � Lam- �- I � l � Lic.Plate <br /> Owner/Operator Name <br /> Business Mailing Address.-'�7 <br /> CityV, _ State6 ' <br /> Zip J5do< Bus. PhArli� YYa ' Vl;d AIL Ph. <br /> 1, �5 1 VII 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 nalties. <br /> Signature[ 1��� Date - <br /> 2.To be completedby COMMISSARY OWNER/OPERATOR <br /> Commissary Name & �vP ( �..FA# <br /> Address 0100Bus. Phone aQ�i /1�I h(_ 4-1570 <br /> City �U C A V1 Zip al'sZo5 OwnerlOperator CC1r,: Q A <-ne t <br /> Check all appropriate services provided:: <br /> Wastewater disposal —"ompartment sink MIR cal hook-ups <br /> Volid waste disposal 0 Food preparation T�"rlet and handwashing <br /> �ot&Cold water for cleaning 13 Stole ; <br /> refrigerated food P table water <br /> ore dry foods ies Overnight parking Vehicie wash <br /> I.L (siU'ILOA -;jV*rrq�E�_ hereby state that the information 1 have provided is current,true and <br /> correct to the best of my knowledge,and meets alifomia Health&Safety Code requirements. If the food facility <br /> operator fails comply with the conn this agreement, or if this agreement is modified or cancelled, the <br /> commissary weer all notify the EHD" ed9atety�_ <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa_tun 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br />