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SAW.JOAQUIN Environmental Health Department <br /> ' ---C O U N T Y----- <br /> ;`_;»':,,,{,'- .)'r$atne4S grows herr. <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 /> Cm fileted b APPLICANT <br /> Business Name Lic. Plate# <br /> Owner/Operator Name / G� <br /> Business Mail' g Address <br /> City StatEC6_Zip a2 Bus. Ph.,�() 7 ��VAlt. Ph. <br /> I, 2 11'5c , hereby state that the above information is current, true and correct to <br /> the best 8f 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 /> 'C� D�� 7`/ <br /> Signature �' Date <br /> 2::6'be c6i� leted by-COMMISSARY OWNER/OPERATOR <br /> Commissary Namec e� —FA# <br /> Address/aD Bus. Ph o e s` � <br /> City Zip aU owner Operator <br /> Check all appropriate services provided: <br /> 6 Wastewater disposal 101 3-compartment sink 14 Electrical hook-ups <br /> 0i Solid waste disposal 0 Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning 0 Store refrigerated food Potable water <br /> 0r0A <br /> dry food/ plies 1A Overnight parking 16 Vehicle wash <br /> 1, /� �-ll�/�/l,�P �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 fai to omply with the conditions s agreement, or if this agreement is modified or cancelled, the <br /> commiss ov�r shall notify the E i ediately. �7 <br /> Signature t Date 1 <br /> 3:`To. be cpm lefedi b the ENV HEALTH 'urisdiction 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 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />