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SAN JOAQUIN E501V iron mental Health 1 �.®ep��. r-,._- <br /> C � i�� TY- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> .'`To be"60MIDIPtPril b APPLICANT = - <br /> Business Name y <br /> ic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City Statezip Bus. Ph. — y: <br /> iAlt. Ph. <br /> I' 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 /> Signature�� <br /> JJ Date <br /> 2_`10 be com leted b COMMISSARY OWNER/OPERATOR <br /> Commissary Name �,� / �, <br /> FAf# <br /> Address_ —Bus. Phone <br /> City � , <br /> Zip � � Owner/Operator <br /> Check all appropriate services Provided.- <br /> Wastewater disposal 3-compartment sink <br /> Electrical hook-ups <br /> Solid waste disposal Food preparation M Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food <br /> ."Potable water <br /> Store dry food/supplies a� Overnight parking 3Nehicle wash <br /> hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledige,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_pobfy the EHD�mMediately. <br /> Signature %��� 7 ' �, Date <br /> 3:-0-be eomMeted b fife 11'"idliv,'yHEALT14 'unsd"iction 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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov_orglehd <br /> �� �t <br />