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SAN J OAQ U I N Environmental Health Department <br /> - -- <br /> COUNTY----- <br /> COMMISSARY <br /> OUNTY_.___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 APPLICANT <br /> Business Name Lic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address <br /> 1,3,;4T-C-c�f _ StateZip�?ZBus. Ph. G� �q-7 ` ' l� Alt. Ph. <br /> 1, c. 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. <br /> Signature s L, , 92fl, Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary NameA I t AUT n L31 c 1 k sem;a( -_FA# <br /> Address 2 VY �s ,�} r a ✓r s Bus. Phone .0 -S6L I yG <br /> City "1 z LSC rl Zip fLy Owner/Operator 1�e��e S 1z�' + <br /> Check all appropriate services provided- <br /> ,E3 Wastewater disposal ® 3-compartment sink M Electrical hook-ups <br /> 11 Solid waste disposal M Food preparation 0 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning -0 Store refrigerated food 0 Potable water <br /> ER Store dry food/supplies 10 Overnight parking R Vehicle wash <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. <br /> Signature '� -"'- Date C1 L-2 s Z <br /> 3. To be <br /> 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 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />