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AQUIN Environmental Health Department <br /> COU NTY <br /> r <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ,} Caterer <br /> Complete sections 9 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed b ,.APPLICANT <br /> Business Name - �, r '" - s Lic. Plate# <br /> Owner/Operator Name^ <br /> Business Mailing Address <br /> City Cti I^ "�, �,. State --Zip p �: -Bus. Ph. <br /> hereby state that the above information is current,true and correct to <br /> the best of my knedge 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 do c.tJc,r0` VIP FA# c o 0 8 1 zu <br /> Address 1 .4,,-, n i+`' I Bus. Phone 1:; 7 a 7 <br /> city Lc'_41,%a r) Zip �'Z�-� Owner/Operator <br /> Check all appropriate services provided: <br /> �/astewater disposal -compartment sink Electrical hook-ups <br /> /Solid waste disposal 2-"'F'ood preparation 2--Toilet and handwashing <br /> HHot & Cold water for cleaning 211store refrigerated food ;-Potable water <br /> Z<I shore dry f d/ I' i�vernight parking =! Vehicle wash <br /> I, Vit;6-2— , 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />