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SA N J O A Q U I N Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections i and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> f. To be Completed! by APPLICANT <br /> Business Name i A Lic. Plate# <br /> Owner/Operator Name �w,r'' ("� Y; ' -�� C� ,;n '^ -k_t. <br /> Business Mailing Address c"�_ �"'C 1�� bi (A fit.: 61 <br /> City , 1 - .:;;r7 State Zip 6--1? Bus. Ph. Alt. 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 Date <br /> 2. To be completed b COMMISSARY OWNERIOPERATOR <br /> .r _ <br /> Commissary Name FA# <br /> Address ^ .� C� Gf ray�[� Bus. Phone �G �f <br /> City �Jrr L Zip 1 s, Owner/Operator ) ? <br /> Check all appropriate services provided: <br /> t Wastewater disposal 0 3-compartment sink C; Electrical hook-ups <br /> Solid waste disposal !Yi Food preparation U Toilet and handwashing <br /> 55 Hot & Cold water for cleaning ki Store refrigerated food Potable water <br /> M' Store dry food/supplies LIM Overnight parking } Vehicle wash <br /> I, , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, and meets the Califomia 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 notify the EHD immediately. <br /> Signature Date <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Jopc pin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in Califomia 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.orglehd <br />