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SAN J OAQ U I N Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility * Caterer <br />Complete sections l and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1 To be cctleted by APPLICANT <br />Business <br />Owner/O{ <br />Business <br />City �kbGk— StateLZipGISZ�IyBus. Ph. H`606400-0 2- Alt. Ph. <br />1, �3 ova- i 0^13, 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 and penaltie <br />Signature Date v C+, 7D 1 2`�Z2 <br />To be com I by COMMISSARY OWNER/OPERNT <br />Commissary Name/�/�/!�'SSYI'z��C� FA# <br />Address („Td Bus. Phone �2D`1� ?Z�✓- $33y <br />City LD L2 Zip 157Z%G Owner/Operator <br />Check all appropriate services provided: <br />wastewater disposal <br />M SSolid waste disposal <br />E HH & Cold water for cleaning <br />a Store dry food/supplies <br />0/'3 -compartment sink <br />Food preparation <br />M Store refrigerated food <br />13"Overnight parking <br />0/6ectrical hook-ups <br />M Toilet and handwashing <br />CV�Potable water <br />VY'Ghicle wash <br />1, , 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 owner shall notify the EHD immediately. <br />Signature_670?`"' Date <br />r L -Z Q -e7` <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 />