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S A NAA Q U I N Environmental Health Department <br /> —COUNTY <br /> Grriitness grows hare_ <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections ? 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 � o Q .T C F CREAM Lic. Plate# A <br /> , <br /> Owner/Operator Name <br /> Business Mailing Address I <br /> City State C Acip 95 33 7 Bus. Ph.? G 2 9 Z 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 by COMMISSARY OWNER/OPERATOR <br /> r <br /> Commissary Name It/ FA# _ _ <br /> Address Bus. Phone 7J T <br /> City Zip , Owner/Operator (03� AAV <br /> Check all appropriate services provided: <br /> t] Wastewater disposal 3-compartment sink Electrical hook-ups <br /> p Solid waste disposal 9q Food preparation Toilet and handwashing <br /> 623\Hot & Cold water for cleaning 17 Store refrigerated food f� Potable water <br /> 42NStore dry food/supplies 4R Overnight parking Vehicle wash <br /> 1, , 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 comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ow r sh Il notifXthHD immediately. <br /> Signature Date <br /> 3. To be completed by 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> I�e2 c,�4,003_+l 11 <br />