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SAN 10 A Q U I N Environmental Health Department <br /> -- — <br /> COUNTY----- <br /> 9 <br /> OUNTY—'--i <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 NamA Lic. Plate# Z <br /> Owner/Operator Name <br /> Business Mailing Address « C, m c-c-, <br /> V V tate Lip s.3 I� <br /> City IU� ���(, �3q Ph. <br /> c A_ L c_ck 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 <br /> 2. To be completed gy COMMISSARY OWNER/OPERATOR <br /> J_ _ <br /> Commissary Name ti r, J, n FA# <br /> Address 2,y VO po/-k Bus. Phone <br /> City LS10 ( V b n Zip !a 1—U 6 Owner/Operator �J 1Z /h: J <br /> Check all appropriate services provided: <br /> 13 Wastewater disposal M3-compartment sink ® Electrical hook-ups <br /> ®'Solid waste disposal 16 Food preparation 0 Toilet and handwashing <br /> 933 Hot& Cold water for cleaning 0 Store refrigerated food Potable water <br /> ® Store dry food/supplies ® Overnight parking WVehicle wash <br /> I, R e'4e 5 1Zv ; c:2 , 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 conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediately. <br /> Signature Date ZZ <br /> 3. To be completed by 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />