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0 Sal 1101 <br /> SAN J O A Q U I N Environmental Health Department <br /> NTY <br /> Greatness grows 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 p' Z ei l l, Lic. Plate <br /> Owner/Operator Name f co-IfloL. - 1�I4141 <br /> Business Mailing Address I \x,1 nt,so0() e+ <br /> city <br /> ��" StateZip c1(9373 Bus. Ph. Alt. Ph. <br /> 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 an en tie <br /> Signature Date \� <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name �.. l !-��if�� �. LP�. �,^,v�cT ,;M���i FA# <br /> Address c-, AUTe r- Bus. Phone <br /> City Zip c, C Z c& Owner/Operator U <br /> Check all appropriate services provided: <br /> S1 Wastewater disposal 3-compartment sink 121f Electrical hook-ups <br /> 14 Solid waste disposal B1 Food preparation jt�,( Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food Potable water <br /> Store dry food/supplies 5r Overnight parking Vehicle wash <br /> I, e4e 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. 11 <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />