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SAN iJOAQUIN Environmental Health Department <br />_ —COUNTY-- <br />i;re grows dere. <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 %� (4) 7 e1 4 C V - Lic. Plate# / I <br />Owner/Operator <br />City Z f Statee-N, Zip 9i' ZBus. Ph.Ztigy// SZ5? - Alt. Ph. '?df 667 <br />I <br />I, ✓ ✓' GZh Z i 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 penalties. -1 1 <br />12. To be completed by COMMISSARY OWNER/OPERATOR I <br />Commissary <br />Name 4-7 d.. UI ) FA# <br />Address 1 7 ? � ��7 Bus. Phone <br />city i� /tG�) ZipOwner/Operator ,54 A/I <br />Ch .,& all appropriate services provided: <br />Wastewater disposal E] 3 -compartment sink 0 Electrical hook-ups <br />CI Solid waste disposal M Food preparation O Toile and handwashing <br />Cl Hot & Cold water for cleaning E3 Store refrigerated foodotable water <br />C Store —0"dry food/supp as Overnight parking O Vehicle wash <br />r�I, Stt� /� I - M'6 , hereby state that the information I have provided is current, true and <br />correct to the estest o�edge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to co y the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary o wrier sha) n the EHD immediately. <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 <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 />