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CL'v <br /> SAN )OAQ U I N Environmental Health Department <br /> COUNTY <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 Lic. Plate# <br /> Owner/Operator Name ! (� �p 2 <br /> Business Mailing Address 2- C),�c)C S� �C 1 k qs2 7 <br /> City tat ZipgS�Bus. Ph.? n, Ck&S% It. Ph.9 j 6- 9,7-1 ; <br /> I, t , hereby state that the above information is current,true and correct to <br /> the best of my knqTedge 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. ff <br /> Signature Date l <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name +.a 0a 9 eg k1) FA# c o b R 12_� <br /> Address 1 4 5 o 4 Bus. Phone ° C 7 o S 3 <br /> City Zip �� 3 Owner/Operator f�A<j, <br /> Check all appropriate services provided: / <br /> O-fastewater disposal �-compartment sink 4 Electrical hook-ups <br /> Solid waste disposal Er"Food preparation Mr Toilet and handwashing <br /> Hot & Cold water for cleaning 0 Store refrigerated food Potable water <br /> p Store dry f od/suppli s �vernight parking 13 Vehicle wash <br /> I, , 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 / - - 2 z 3 <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 />