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Department <br /> Environmental Health De a <br /> SAN �JOAQUIN p _ <br /> COUNTY <br /> -r Greatness grows he '_r V (✓ 2 �� <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 /> 1. To be com fefed ` -APPLICANT <br /> Business NameLic. Plate# V�al7s <br /> Owner/Operator Name <br /> Business Mailing Address j�;/Z2 <br /> Cit y%� i� StateeZip 5.337 Bus. Ph.9o?S-6��b 3��Alt. Ph. <br /> I,�dZOMr'5 Ci/w 1/eZ 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 /> 2 <br /> Signature Date�0� 7 ���?_�_ <br /> 2. To be completed b . COM ISSARY OWNER/OPERATOR. <br /> Commissary Name FA# <br /> Address o�'?UO Bus. Phon <br /> City ZipOwner/Operator � <br /> Check all appropriate services provided: <br /> [I Wastewater disposal 6 3-compartment sink t Electrical hook-ups <br /> It Solid waste disposal ® Food preparation U Toilet and handwashing <br /> 0 Hot & Cold water for cleaning © Store refrigerated food 6 Potable water <br /> ® Sr ry food/su lies El Overnight parking (3 Vehicle wash <br /> l O�o(!i �ANA� hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, a d"meets the California Health &Safety Code requirements. If the food facility <br /> operator s to co�ply with the_ aditions of this agreement, or if this agreement is modified or cancelled, the <br /> commisC757 <br /> wpi'shall notify tfa :EHD immediat n <br /> Sig natu �� _4'_ c��rR=E Date <br /> 3. Tobe completed Oy 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 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />