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SAN J OAQ U I N Environmental Health Department <br /> -----'COUNTY- <br /> COMMISSARY <br /> OUNTYCOMMISSARY 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 Com )* gib: APPLICANT <br /> Business Name - v Lic. Plate# <br /> Owner/Operator Name C� <br /> Business Mailing Address '�"/U <br /> City State Zip Bus. Ph. Alt. Ph. <br /> I, ,�C��O PS 6� VeZ- , 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, th a holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penal ' <br /> Signature Date ��ZS /2 <br /> 2. To be.completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address vZgOD Bus. Phone2kqL <br /> � <br /> City Zip G(� D Owner/Operator <br /> Check all appropriate services provided: <br /> Eg Wastewater disposal 6 3-compartment sink Electrical hook-ups <br /> It Solid waste disposal 13 Food preparation ® Toilet and handwashing <br /> 1131 Hot & Cold water for cleaning 0 Store refrigerated food 6 Potable water <br /> ® S revelry food/su plies El Overnight parking 6 Vehicle wash <br /> I, Osyo1li� Cf�lt/plC 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 faifs to co ply with the�c editions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owt� shall notify the EHD immediat _ <br /> Signature `7 L,`c� -��L cG� -- Date <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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />