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revocation and penalties. <br />Signature <br />1 <br />SAN JOAQUIN <br />--COUNTY <br />rIeSs <br />Environmental Health Department <br />Nizi-(032.cm <br />COMMISSARY AGREEMENT <br />Mobile Food Facility 4 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 />kkAV <br />Owner/Operator Name <br />Business Mailing Address __e • <br />City YT. State QA Zip 9 STAg Bus. Ph ci - -t) -3 SI?it‘lt. 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 />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br />commissary is discontinu permit holder must notify the EHD. Failure to notify this office may result in permit <br />Business Name Lic. Plate # RS 1154- <br />c`• <br />Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name V'kc\c-- FA# <br />City c\-bci den Zip S7o Owner/Operator Cs.hv..". <br />Bus. Phone q <br />Check all appropriate services provided: <br />E:3 Wastewater disposal 0 3-compartment sink <br />Solid waste disposal <br /> <br />O Food preparation <br />Hot & Cold water for cleaning <br /> O Store refrigerated food <br />Store dry food/supplies <br /> Overnight parking <br />18- Electrical hook-ups <br />Toilet and handwashing <br />Potable water <br />Vehicle wash <br />Address (3)4D- WV,&.ec- av.e <br /> , hereby state that the information I have provided is current, true a <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facili <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, th <br />commissary owner shall notify the EHD immediately. <br />Signature (5:x4 <br /> <br />Date <br /> <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin 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 />RENS Signature Date <br />1868E. Hazelton Avenue I Stockton, California 95205 I 1 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd