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SAN,r10AQUIN Environmental Health Department <br /> COUNTY-- <br /> Greatii, pr hats. <br /> %opy <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' Ple't6d"'by APPLICANT <br /> 14 <br /> Business Name Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address Y q <br /> City StateL4+ zip 9Syly Bus. Ph. o�� /` ��d`AeAe"AIt. Ph. <br /> crAJZ— 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 Counyj Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the per it ho er must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. /! <br /> Signature Date '7 a_/ <br /> .2:To be completed` ;'COMMISSARY WNER/4PERATOR <br /> !/ <br /> Commissary Name �� FA# <br /> Address v —Bus. Phone <br /> City zipq d Ow er/Operator �- <br /> Check all appropriate services provided: <br /> Ed Wastewater disposal t 3-compartment sink It Electrical hook-ups <br /> 1§ Solid waste disposal © Food preparation 10 Toilet and handwashing <br /> 6 Hot & Cold water for cleaning ® Store refrigerated food Potable water <br /> 0 S e dry food/supplies it Overnight parking LSI Vehicle wash <br /> rt Z hereby state that the information I have provided is current,true and <br /> correct to the b t of my knowledge, and-Meets the California Health &Safety Code requirements. If the food facility <br /> operator f ' to c mply with the co +tions of this agreement, or if this agreement is modified or cancelled, the <br /> commiss ry ow r shall notify t HD immediately. �/ r /l3 — <br /> Signatur Z — Date / <br /> & To be color let�db . the ENV HEALTH`'urisdiction 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 209 464-0138 1 www.sjgov.org/ehd <br />