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? r sr t <br /> SAN 10AQUIN Environmental Health Department <br /> COUNTY- <br /> C 'S-o"' Greatness grows fere. <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 APP <br /> LICANT <br /> Business NameI Lic. Plate# !. U if <br /> Owner/Operator Name <br /> Business Mailing Address 3L(2) L L M 5-f-rce_t <br /> City Lc State (j,Zip Bus. Ph. 9-S yk Alt. Ph. <br /> I,:1o5C_ 6'U G6 I'j)_T r,.Q T 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 <br /> •-and penalties. <br /> Sig nature_1an6� Ic , Date <br /> 2. To be completed by COMMISSARY Oj MER/OPERATOR <br /> Commissary Name (� (�� FA# <br /> Address /��(1/ s4cr���s, S�" Bus. Phone 11' DOgl <br /> City ,,; / Zip ����%/) Owner/Operator (�%„�., /y c�rr�j <br /> Check all appropriate services provided: <br /> [W Wastewater disposal 13 3-compartment sink 'M Electrical hook-ups <br /> Solid waste disposal [3 Food preparation 1l Toilet and handwashing <br /> 6 'Hot &Cold water for cleaning 0 Store refrigerated food Q Potable water <br /> E3 Store dry food/sup lies IR Overnight parking Vehicle wash <br /> I, � ✓ hereby state that the information I have provided is current,true and <br /> correct to the best of my kn ledge, 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 notify he '-I immediately. <br /> Signature A Date <br /> 3. To be completed 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 />