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SANJOAQUIN Environmental Health Department <br /> —COU NTY— <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 7 / <br /> Business Name ^� t� �I����te��U Lic. Plate# D ZS S <br /> Owner/Operator Name6�D'e� <br /> Business Mailing Address 7/� i7 o, te- <br /> City State CAZip Z�Z Bus. Ph. zo9 yY'6;'ZJ Alt. Ph. <br /> I, jPlw �90me Z�- 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. <br /> Signature Date c1 <br /> 2. To a competed by COMMISSARY OWNER/OPERATOR <br /> CommissaryNam a FA# <br /> Address ,6 &La4 Bus. Phoned0 <br /> /9Q- -lf5 r/O <br /> City +j-� Zip gS Owner/Operator <br /> Check all appropriate services provided: <br /> it Wastewater disposal 10 3-compartment sink M Electrical hook-ups <br /> d Solid waste disposal 13 Food preparation 0 Toilet and handwashing <br /> E3 Hot & Cold water for cleaning 13 Store refrigerated food 10 Potable water <br /> Orre dry fLood/supplies 10 Overnight parking 0 Vehicle wash <br /> Or <br /> ,9 /fAA6 't&Z , 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 co ions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary er shall notify t HD immediately. <br /> Signature -`—^ Date 3 -� - 4� <br /> 3. To be com leted b the ENV HEALTH jurisdiction outside of San Joa uin 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 />