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SAN JOAQUIN Environmental Health Department <br /> - --COUNTY--— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4, 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 <br /> completed by APPLICANT <br /> Business Name ���c�r;w 6 c Lic. Plate# <br /> Owner/Operator Name 'iz� <br /> Business Mailing Address `� ^�CZ�r��� <br /> Ch t1-t c..� State(LA Zip j�,3­?j-Bus. Ph. 7,!A Cq-7 al� Alt. Ph. <br /> 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 p a//ties. d <br /> Signature Li' � �2'Ez' Date <br /> 2. To be <br /> completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name�_q I rP��_FA# <br /> Address 2 VYG) ' %raCr+ c.y Bus. Phone— <br /> �-�6 <br /> City "��—v Ci;��.�� Zip—!2 fy Owner/Operator <br /> Check all appropriate services provided. <br /> - <br /> -E3 Wastewater disposal ® 3-compartment sink M Electrical hook-ups <br /> (y Solid waste disposal W Food preparation Toilet and handwashing <br /> * Hot & Cold water for cleaning ii Store refrigerated food Potable water <br /> * Store dry food/supplies W Overnight parking W' Vehicle wash <br /> I, <br /> hereby state that the information I have provided is current, true and <br /> correct t6 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. f <br /> Signature a"_ �—� — Date �l 2 S z_3 __ <br /> 3. To be completed 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 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />