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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <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 r, .�i c ,\ 4,,��i K = 1, Lic. Plate# \,4 C Li 121 <br /> Owner/Operator Name �- <br /> Business Mailing Address =- <br /> City lah� State`L Zip _ C ; SC: Bus. Ph. i O`1= l�. -[r C� Z tAIt. Ph. <br /> I, pct, I,,J i i`k �i L\c!,VI , 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, an San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is iscontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation an enalties. <br /> Signature �i ��!� <br /> Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name ? � zZ FA# <br /> Address_ �'��/ (� s o^r':/v , 1 �- Bus. Phone_/ <br /> City i­z Zip Owner/Operator / `✓��' -�,�; /'�' , <br /> Check all appropriate services provided: <br /> Wastewater disposal Y 3-compartment sink Electrical hook-ups <br /> ,-?''Solid waste disposal Food preparation Toilet and handwashing <br /> - 'Hot& Cold water for cleaning ,_?Store refrigerated food Potable water <br /> IM Store dry food/supplies Overnight parking Vehicle wash <br /> 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 otify the EHD iiroinrediately. <br /> Signature �— ' Date <br /> 3. To be completed by the ENV HEALTH 'urisdiction 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 i F 209 464-0138 1 www.sjgov.org/ehd <br />