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A N J U A Q U I N Environmental Health Department <br /> J, L-i rt COUNTY <br /> reakness draws here. <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 completed by APPLICANT <br /> Business Name 0S MA r GI Lic. Plate# <br /> Owner/Operator Name �'1 ��! S r3 O P;i V1(D S <br /> Business Mailing Address -F1C1'f" �U{ <br /> City S +G� State C4 Zip q,52c)1P Bus. Ph. Alt. Ph. <br /> I, C'1 �d 5 (�iJ�(n✓l�j 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 Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name It SU W)4 FA# <br /> Address , i('D(N� fN !, Bus. Phone <br /> Cit is 6(,kbA Zip ' Owner/Operator Ime«IP_.� D <br /> Check all appropriate services provided: <br /> M-Wastewater disposal 0 3-compartment sink 4rElectrical hook-ups <br /> (� Solid waste disposal 10 Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning 19 Store refrigerated food Potable water <br /> WSto dry food/supplies 4 Overnight parking 116 Vehicle wash <br /> I ��_ jig) , 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 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 <br /> 3. To be completed by the ENV HEALTH jurisdiction 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 I T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />