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SA N J OQ Q U I N Environmental Health Department <br /> _.....COUNTY ... <br /> _. <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 /> 1. To be completed_by APPLICANT <br /> Business Name C'�_,LR <br /> Lic. Plate <br /> Owner/Operator Name t <br /> Business Mailing Address r�� <br /> � J <br /> City C0 State("M Zip G���,. Bus. Ph. �2c ��(v , ,,' � f Alt. Ph. <br /> 1, , 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 pens)ties. <br /> Signature _ Date <br /> T Q 1 — 2 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name P E C K . rv' c, y 4. r pe f,,m FA# <br /> Address 3cf I n, � EQ VU Bus. Phone <br /> City_f.,(—C)C W Zip_ S��'J 5, OW6r/Operator <br /> Check all appropriate services provided: —4 w 0 <br /> O T <br /> ® Wastewater disposal D 3-compartment sink Electrical hook-ups 0 n� Z <br /> D Solid waste disposal C7 Food preparation <br /> P p p Toilet and handwashing X m 0 <br /> 0 Hot & Coldwater for cleaning Store refrigerated food Potable water Z Z O <br /> 13 Store dry food/supplies ,Overnight parking Vehicle wash D X rn <br /> I, , hereby state that the information I have provided is current, true andto D ,X <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facifityN m m <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the O . D <br /> commissary owner shall notify the EHD immediately. 3 <br /> Signature f a� Date <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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> ?o 2c30o2L cv <br />