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SAN-)IOAQUIN Environmental Health Department <br />—COUNTY— <br />COMMISSARY <br />COUNTY— <br />COMMISSARY AGREEMENT <br />Mobile Food Facility a Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1. Tobe completed,by APPLICANT y�c/ <br />Business Named ✓3d,o--jL,,A c_ rL t j 1lt Lic. Plate # <br />Owner/Operator I <br />Business Mailing <br />e; <br />Cit//yi 9 Stat�i Zip S . 7. Bus. Ph.at'f- 77y- GS -SL Alt. Phil d � -699 <br />(2 / <br />I,_ Cf 1,id � - h, V a U CL , hereby state that the above information is current, true and correct to <br />the best of my knowledge arfd 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 discpptinued, the permit older must notify the EHD. Failure to notify this office may result in permit <br />revocation apol pe ties. / 7 <br />cneck all appropriate services provided: <br />0 <br />Wastewater disposal <br />11A 3 -compartment sink <br />10�11 Electrical hook-ups <br />Ij <br />Solid waste disposal <br />0 Food preparation <br />C1 Toilet and handwashing <br />0 <br />Hot & Coldwater for cleaning <br />® Store refrigerated food <br />I5 Potable water <br />St -i - re dry food/supplies Overnight parking IA Vehicle wash <br />I, (yyit/it j �A' AIANVd -7 , 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 c ditions of this agreement, or if this agreement is modified or cancelled, the <br />commissaryer, shall notify )jF�`HnD immediately. <br />3. To be cord`" leted °the-ENWHE &TH 'uhsdiction oyts de�of sa l'J�aa uin Co. <br />The commissary is located in County. The above food facility meets the <br />commissary requirements i alifomia Health & Safety Code. The above checked services are available at the <br />above commissary/Peas tify EHD if tXe status of their operating permit changes. <br />REHS <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />