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S A N J O A Q U I N Environmental Health Department <br /> COUNTY <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 d �)yoI(A �P 1(j> Lic. Plate# 3 1 <br /> Owner/Operator Name Lic,1 Ylfl�/,�,�L��(1 — - <br /> Business Mailing Address l�6 ? Loa, <br /> city_ 7M State (O-ZipZ`'t� Bus. Ph.(2;, " ) �-`lS 3AIt. Ph. <br /> hereby state that the above information is current, true and correct to <br /> the best of Ky 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, he permit holder must notify-the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. 1/ <br /> Signature �� Date <br /> ZZ <br /> 2. To be compleE#' by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L ' FA# 0 <br /> Address (P a o d Hjq 0 r�J 'R(4_ Bus. Phone a-201 -�I,���(o <br /> City 4/a4 bc,0 Zip .00wner/Operator feevt– <br /> Check all appropriate services provided: <br /> Wastewater disposal ❑ 3-compartment sink Electrical hook-ups <br /> r Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> El Hot & Cold water for cleaning ❑/Store refrigerated food Potable water <br /> D Store dry food/supplies L!Q Overnight parking [� Vehicle wash <br /> I, trlohereby 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 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 Z <br /> 3. To b 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 209464-0138 1 www.sjgov.org/ehd <br /> G <br />