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SAN -JOAQUIN En rolilmsn <br /> —COUNTY— <br /> r 1 E S s <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer - <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> ..bYAPPLICANT . 7 <br /> Business Name <br /> r n Plate# <br /> Owner/Operator Nam a,11-e <br /> Business Mailing Address AL17 <br /> City_2j_U,1X_j,j_State 3 , Bus 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 /> 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 /> V <br /> Signature _ -Date <br /> feted_bT S ARY OW11 111 -ATQR <br /> O __C-__ <br /> -01MMI71 <br /> Commissary Name <br /> FA# <br /> Address_ <br /> &Z Bus. Phone <br /> City <br /> ZiP Owner/operator <br /> Check all appropriate services provided. <br /> Wastewater disposal ISL 3-compartment sink <br /> 4'Electrical hook-ups <br /> Solid waste disposal E2 Food preparation 'ECToilet and handwashing <br /> Hot& Cold water for cleaning �: Store refrigerated food W'Potable water <br /> hr-1 Store dry food/supplies a-11,Overnight parking 1XVehicle wash <br /> > hereby state that the information I have provided is current,true and <br /> correct to the best of rriy know)e e,and meets the California Health&Safety Code requirements. If the food facility <br /> ,4- - - <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shalij3otify thq EI-IDtimmediately. <br /> Signature <br /> Date— <br /> Pe <br /> T6b"' ted by the_ . HFALTHjurisdiction outside of San Joaquin <br /> 3 00 _9�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 />