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r;CwIV <br /> ''�� SAN -JOAQUIN Environmental Health Department <br /> ,z <br /> --COUNTY <br /> Greatness grows here. <br /> -5 <br /> COMMISSARY AGREEMENT str �c O' <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 /> /\1 C <br /> Business Name j A Lic. Plate# 3 5 S 2-�' ` <br /> Owner/Operator Name r , 1A L 01-- <br /> Business Mailing Address 7.3 0 1 /V JA ra4l!vw S <br /> City S-�G kin State C. Zip ?-o Bus. Ph. S_-/zi _("Z�lZ 93Alt. Ph. <br /> I, 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 Z Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FFAA# 1 <br /> Address Bus. PhonelL����p <br /> City Zip Owner/Operator <br /> Check all appropriate services provided: -* (� . E)( OL-A- vAJoV-� <br /> ❑ Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ St�refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies Overnight parking ❑ Vehicle wash <br /> 5c hereby state that the information I have provided is current, true and <br /> correct to the best of knowledge, and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to c ply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commiss I notify the EHD immediately. <br /> Signatur Date 11122- <br /> F3, 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 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />