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SAN J O AQ U I N Environmental Health Department <br />COUNTY— <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 b APPLICANT <br />Business Name De�G/1 CTa v1 ✓� S y �4� f�� Lic. Plate # <br />Owner/Operator Name MI C -4-1k2 <br />Business Mailing Address 7,M- A411 ,j Mcacfevi l¢ . <br />City S7� Ck--7%1-1 State Zip ?IWr%Bus. Ph. °6 9-3k;�J 6y It. Ph. <br />c <br />I,lVI l��� �n�� , hereby state that the above information is current, true and correct to <br />the best of my knowledge and agre 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 penalties. _ <br />f ay - >V -LZ <br />12. To be completed by COMMISSARY OWNER/OPERATOR I <br />Commissary <br />Check all appropriate services provided: <br />Wastewater disposal )SO -compartment sink ❑ Electrical hook-ups <br />j� Solid waste disposal Food preparation Toilet and handwashing <br />Hot & Cold water for cleaning ;' Store refrigerated food g Potable water <br />Store dry food/sup lies // ❑ Overnight parking ❑ Vehicle wash <br />I, 17a hereby state that the information I have provided is current, true and <br />correct to the bestlof my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the con itions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shongtify the EAD immediigt". ^ ( - f <br />Z 2-- <br />13. To be completed by the ENV HEALTH iurisdiction outside of San Joaquin Co. I <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 <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 />