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SAN ,-IOAQUIN Environmental Health Department <br /> --- C O U N TY- <br /> --COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 C <br /> Business Name ' LLC Lic. Plate# yl U <br /> � a . o <br /> Owner/Operator Name0 ;� <br /> Business Mailing Address I 'l Ll I L G V L �_�,5 fyD <br /> City Or k TQ/VState GgZip 95 2 o G Bus. Ph. 2 0 7-,30,2--2.?0 ZAIt. 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 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 an alties. jj�� <br /> Signature Date�.l IC 2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name / ' / FA# <br /> Address / 0W f J 6;i/Vfzieh ti Bus. Phone r�-P5�) <br /> CitZip �l_�1 t/��owner/operator_ f��ZlIj <br /> Check all appropriate services provided- <br /> V Wastewater disposal ❑ 3-compartment sink tS( Electrical hook-ups <br /> ' 'Solid waste disposal ❑ Food preparation IrToilet and handwashing <br /> Hot& Cold water for cleaning ❑ Store refrigerated food 1�1-Potable water <br /> ® Store dryyfo>od/supplies ❑ Overnight parking �Vehicle wash <br /> 1, /�f -e/ , hereby state that the information I have provided is current,true and <br /> correct tothe l5est 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 tify th;eHD i diately. <br /> Signature Date —�J)�.� <br /> 3. To be completed b the �N 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 />