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o s�' 57 <br /> SANJOAQUIN Environmental Health Department <br /> COU NTY----- <br /> C.��•_.t[n�s. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections 9 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 Namey Lic. Plate#_I <br /> Owner/Operator Name OY= <br /> Business Mailing Address l 7 [1Cj no� <br /> City fiv Jl+� C k StateZip �3 ej o Bus. Phi`L�plc OG �TAIt. Ph. <br /> <�ti<« .,�? hereby state that the above information is current,true and correct to <br /> the best of my knowle a 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. <br /> Signature -10"il V- e- Date_ <br /> 2. To be complete#by COMMISSARY OWNER/OPERATOR <br /> Commissary Name -jaFA# �O� 9 <br /> Address 2 dti f}r' ►� ,'1 Bus. Phone 7j 2 41(g <br /> CityZip Owner/Operator f.2V'r_ <br /> Check all appropriate services provided: <br /> Wastewater disposal ❑ 3-compartment sink Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation try! Toilet and handwashing <br /> ❑ Hot& Cold water for cleaning ❑ Store refrigerated food l(Potable water <br /> ❑ Store dry food/supplies Overnight parking C?' Vehicle wash <br /> hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledgefand 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 own hall no ' e EHD immediately. <br /> Signature Date 7 2- <br /> 3. To_b completed b .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 cinnv nrn/ahri <br />