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t _ <br /> SA N.d J O A Q U I N Environmental Health Department <br /> '.•=1' COUNTY-- <br /> Greotnes<. <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 Q { <br /> Business Name�A C o �� y / I� A ic. Plate# <br /> Owner/Operator Name� V <br /> Business Mailing Address G/ �7� d A 1N �/,T <br /> If <br /> City StateC_AZip g Bus. Ph.2,,) r ,3 -7 Z Alt. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> the b t 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 penaltie . <br /> Signature Datef/ 2 [) <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address .01 1/ Bus. Phone 47v 9 7f2 T <br /> City Zip Z u/j Owner/Operator OMK <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink Electrical hook-ups <br /> Solid waste disposal 0 Food preparation FToilet and handwashing <br /> 1 Hot & Cold water for cleaning 0 Store refrigerated food F, Potable water <br /> 0 Store dry food/supplies F- Overnight parking Vehicle wash <br /> I, /4 d e� f7i�Gfa <br /> g42r , hereby state that the information I have provided is current,true and <br /> correct to the best of my knqWiedge, 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 tify th EHD mediately. <br /> Signature Date /Z x- <br /> 3. To be completed by the L6W 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 />