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SAN.�J 0 A Q U IN 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 1lIq 1 C-�' C TE EA N G= Lic. Plate# 3 <br /> Owner/Operator Name 6/t'�N <br /> Business Mailing Address 1923LE-_K-3 VJ S'9C_-)MS UVA F <br /> City M4 MT-0" State�4�ip�Bus. Ph. �CIt.IPh. �2 <br /> I, Fjjii- y1 � , 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 by COMMISSARY <br /> /OWNER/OPERATOR <br /> Commissary Name lYG C (r // FA# <br /> Address '/ // f 42 f Bus. Phone <br /> City �A /) Zip Ff c/A Owner/Operator l <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink ❑ Electrical hook-ups <br /> Solid waste disposal ❑ Food preparation q Toilet and handwashing <br /> EZ Hot & Cold water for cleaning ❑ Store refrigerated food Ek-Potable water <br /> ❑ Store dry <br /> yfood/supplies ❑ Overnight parking 6�Vehicle wash <br /> I, � ) , 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 t EHD igimediately. <br /> Signature Date <br /> 3. To be completed b the EN 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 209 464-0138 1 www.sjgov.org/ehd <br />