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SAN JOA IN Environmental Health Department <br /> <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />comp/ore sections 1 and 2 If yotit contrtisssary as located outside of San dhio coiniActe SVCROn 3 <br /> <br />Li. To be completed by APPLICANT <br />Business Name - A <br /> <br />_ Plate # _S <br /> <br />Owner/Operator Name v <br /> <br />Business Mailing Address /0 4. •. <br />City (--). L State _A Zip \ Bus. Ph.,j& ' ' Alt. Ph <br />I• • - - , that the above information is current, true and correct to <br />the best of my knowledge. and agree to utilize my a';• id commissary in accordance with California Health & <br />Safety Code. and San Joaquin County Environmental Health Department (E HO) requirements. If the use at the <br />commissary is discontinued the permit holder must notify the EHD Failure to notify this office may result in hermit <br />revocation and_Renaltras.----) <br />Signature <br /> <br />Date _ 14 7) <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name_CON,WAN &Gato uoc‘) 5,39- SO <br />Address_ Upt SaChr_aftat[7__ S_t_Bus. Phone coo 2513 <br />City L Zip CI5V19 Owner:Operator eAN).e2kip <br />Check all appropriate services provided <br />3-compartment sink <br />Food preparation <br />Store refrigerated food <br />Overnight parking <br />0 Electrical hook-ups <br />Ed Toilet and handwashing <br />0( Potable water <br />el Vehicle wash <br />Ef Wastewater disposal <br />fa' Solid waste disposal <br />EllHot & Cold water for cleaning <br />0 Store dry foo /supplies j <br />I. ell A7/67 e7 /11141(ZY f). <br />correct to the best of my knowledge, and <br />operator fails to comply with the co <br />commissary own /tall notify the <br />Signature <br />,• hereby state that the information I have provided is current, true and <br />meets the California Health & Safety Code requirements. If the food facility <br />of this agreement, or if this agreement is modified or cancelled, the <br />ediately. <br />Date 12- 1—Z3 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co7. <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 />1866E Haze1tori Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.soov,org/ehd