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FAF 00-2-7 Y`-1 <br />SAN JOANN Environmental Health Department <br />COUNTY <br />COMMISSARY AGREEMENT <br />Mobile Food Facility o 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 <br />by APP�LIICANT/ <br />Business Name <br />T 9 ►q /Z; <br />14 v4114 <br />j �r <br />66. <br />Lic. Plate # <br />Owner/Operator Name_ <br />Business MailiingAddre <br />City 15:21Vyq' <br />-1 -4t. 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 pen ies. <br />12. To be compleby COMMISSARY OWNER/OPERATOR <br />Commissary Name A-Jr-Qp J©o a FJA 7 /3 FA# ioo g 7 4 9 <br />Address 2 0 1i'0ra r4 _Bus. Phone X09 - <br />city y�zipZowner/operator i V <br />Check all appropriate services provided: <br />0 Wastewater disposal O 3 -compartment sink Electrical hook-ups <br />® Solid waste disposal O Food preparation Toilet and handwashing <br />® Hot & Cold water for cleaning 0Store refrigerated food P(PPotable water <br />© I$ <br />Store dry food/supplies "/ Overnight parking W Vehicle wash <br />I, Sj[ryt(ltt _, hereby state that the information I have provided is current, true and <br />correct to the best of my knowledgefand 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 ownglshall nolify'tjie EHD immediately. / <br />3. To b 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 <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 />