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Environmental Health Department <br /> SAN J0A0UIN p <br /> COUNTY <br /> Gr-ectness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 <br /> completed by APPLICANT <br /> Business Name Lic.Plate# <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City State Zip Bus. Ph. Alt. Ph. <br /> 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 /> jSafety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> 11 commissary is discontinued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> \ Signature Date <br /> 2. To be completed b COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address // y /lAy/'F= PP 4/ #'V e Bus. Phone/ rl O? 5? f, —;? <br /> City TOC 10"i Zip A' Owner/Operator r/✓4 h ./w �r7'"W/ - <br /> Check all appropriate services provided: <br /> p Wastewater disposal D 3-compartment sink 13 Electrical hook-ups <br /> D Solid waste disposal D Food preparation D Toilet and handwashing <br /> O Hot & Cold water for cleaning O Store refrigerated food D Potable water <br /> D St re dry food/supplies Overnight parking D Vehicle wash <br /> pr/Iy�C//� , 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 ow er shall notify the EHD immediately. <br /> Signature , /a, zee `— Date 0.1 �- <br /> 3. Tobe comm letedbthe'ENV'HEALTH 'unsdlction off` SWZd f<San Joa 'C 0. <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 />