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SANAAQN Environmental Health Department <br /> E.•,}� ti COUNTY <br /> Or <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s Caterer <br /> Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 1 . To be completed by APPLICANT <br /> Business Name 1 l � � Lic. Plate# <br /> Owner/Operator Name �� <br /> Business Mailing AddressG - <br /> city C StateaZip Bus. Ph.1211�5 lit. 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 discontinue , the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation an Pena ies _ �1 <br /> Signature Date-0_ C rL <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR - <br /> Commissary Name nT c] C K U sl: A A�i� <br /> Address y N [ON _Bus. Phone � 12C� L � l Lz - <br /> City i�i Zip t' OwnerlOperator - � Q � <br /> Check all appropriate services provided: \;J <br /> -j Wastewater disposal A 3-compartment sink `J ID Electrical hook-ups <br /> Solid waste disposal fA Food preparation t)d Toilet and handwashing <br /> �[ Hot & Cold water for cleaning [3 Store refrigerated food Potable water <br /> p Store dry foodlsuppliu © Overnight parking Vehicle wash <br /> I 7 S 6 , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge, and meets the California Health &Safety Code requirements. if the food facility <br /> operator fails to y w' onditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary c ne sh no t EHD immediately. II`` <br /> Signature Date ZV 2 <br /> 3, To e com feted b the ENV HEALTH jurisdiction outside of San Joa uin 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 95205 1 T 209 468-3420 1 F 209 464-0138 j www.sjgov.org/ehd <br /> WMS109 <br />