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SAN J OAQ U I N Environmental Health Department <br /> -COUNTY----- <br /> s <br /> COUNTY-----s 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 NameCom Lic. Plate <br /> Owner/Operator Name C A C,tW l(C-1 <br /> Business Mailing Address _2V K J11ul t(I(Al t <br /> City Ch vN State_c�iZip Bus. Ph. Alt. Ph. <br /> I, , 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 Sj (10� Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name 11 err() Lot 0c x r�tj c, V221 I_FA# <br /> Address 2 9b k kr',ur-=- wck_� Bus. Phone <br /> City 5+Q CCS Zip ti CZE L Owner/Operator P-4 )ud b i U <br /> Check all appropriate services provided: <br /> Wastewater disposal 15� 3-compartment sink PrElectrical hook-ups <br /> Solid waste disposal 6 Food preparation LVToilet and handwashing <br /> Hot & Cold water for cleaning )10 Store refrigerated food Z Potable water <br /> Store dry food/supplies [ Overnight parking Vehicle wash <br /> , hereby state that the information I have provided is current, true and <br /> correct to thea,s 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. `r <br /> Signature Date Y Z <br /> 3. To be completed by 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 />