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SANJOAQUIN Environmental Health Department <br /> F! —COUNTY— <br /> ,, Greotness grows here. <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 V Lic.Plate# <br /> Owner/Operator Name Nino <br /> Business Mailing Address )`L__E, t lkof– , <br /> city V\ State�LZipq�5 Bus. Ph..3A %5!� Alt. Ph. <br /> 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 S Joaquin County En ' onmental Health Department (EHD) requirements, If the use of the <br /> commissary is d' co 'nue , h er hol a must notify the EHD. Failure to notify this office may result in permit <br /> revocation an en ies. a <br /> Signature t 1l J Date \ 1 ZZ <br /> 2. To be completed b OMMISSARY OWNER/OPERATOR <br /> Commissa pNam Q FA# �/ <br /> Address /�Q ,,00,.,�� �!4d_4,or Bus. Phon[p, �9– 7"lP <br /> City rk 61 Zips dG� Owner/Operator_ ZZ2 <br /> Check all appropriate services provided: <br /> 16 Wastewater disposal 19 3-compartment sink t1f Electrical hook-ups <br /> I§ Solid waste disposal ❑ Food preparation 6 Toilet and handwashing <br /> b Hot & Cold water for cleaning ❑ Store refrigerated food If Potable water <br /> ❑ or dry fgod/suppil � n Of Overnight parking L Vehicle wash <br /> I, Opll/jll� V���' , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, nd meets the Califo is Health &Safety Code requirements. If the food facility <br /> operator fails to comply with the nditions of this agree t, or if this agreement is modified or cancelled, the <br /> commissary er shall noti a EHD immediately. <br /> Signature Date a-"a <br /> 3. To be com leted 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 /> ��05�180q 3 <br />