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SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> c�c, �'. Greocntst g o;os here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility � Caterer <br /> Complete sections 9 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 `� I ��"��r� .�;�s c�;c e Lic.Plate# "f 3 B Ll <br /> Owner/Operator Name G, <br /> Business Mailing Address l r,(.1 11 <br /> City 00 h State c-. i Zip �' o - Bus. Ph. 2-Alt. Ph. <br /> I, CU 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 /> Signatures' Date <br /> 2. To be Completed by COMMISSARY OWNER/OPERATOR <br /> t�� .!,FA# <br /> Commissary Name (��i � h.I c, ( D, R i '� 5� ; <br /> Address Z V ,Y L S. Bus. Phone ?_c?!�j - <br /> City 5 4=(-I(kAA Zip Owner/Operator_S j7;,►-� ; <br /> Check all appropriate services provided: <br /> Ij Wastewater disposal 12F 3-compartment sink 11 Electrical hook-ups <br /> 11 Solid waste disposal 13 Food preparation 13 Toilet and handwashing <br /> 53 Hot& Cold water for cleaning 10 Store refrigerated food 19 Potable water <br /> Store dry food/supplies Overnight parking M'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 notify the EHD immediately. <br /> Signature -�'`J Date 2. Z � <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of SaM�o. <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 /> "� 0 5y �elf V 5 <br />