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SAN JOAQUIN Environmental Health Department <br />Greainess jru::t, 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 com letecl b APPLICANT t , 5 L� <br />Lic. Plate # <br />Business Name <br />Owner/Operator Name l USS <br />Business Mailing Address '' la Alt. Ph. <br />CitySkd_ C \ State(_ zip a us. Ph. y��'3a� <br />I, Luk S 1 ,C _. hereby state that the above information is current, true and correct to <br />the best of my know) dge and agree to utilize my approved commissary in accordance with California Health & <br />ment (EHD) requirements. If the use of the <br />Safety Code, and San Joaquin County Environmental Health Depart <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation <br />2. To be <br />Commissary <br />3 <br />OWNER/OPERA' <br />ILI <br />will �l.L/ <br />Check all appropriate services provided: 10 Electrical hook-ups <br />lt wastewater disposal it 3 -compartment sink <br />6( Solid waste disposal <br />D Food preparation 11 Toilet and handwashing <br />El Hot & Cold water for cleaning 0 Store refrigerated food 0 Potable water <br />E3 r dry foodAupplies Et <br />Overnight parking 0 Vehicle wash <br />i �^/�/���_ hereby state `.hat 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 ditions of this agreement, or if this agreement is modified or cancelled, the <br />c <br />commissary oyer shall notifyHD immediately._ S _ � _ -;? o <br />3 To be completed by the ENV HEALTH jurisdiction outside of San Joaquin L;O. <br />County. The above food facility meets the <br />The commissary is located in <br />commissary requirements in California Health & Safety Code. <br />Th9 above <br />t chankes services are available at the <br />above commissary. Please notify EHD if the status of their operating p 9 <br />REHS Signature <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 />