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SA N d O Q Q U I N Environme <br /> ntal Health Department <br /> COUNTY--- <br /> Nor <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 /> t T6be-begil + leted by APPLICANT <br /> Business Name?j if y1_e y�C� i0 e LCA R-i XLn(k_Lic. Plate#q\1 1 <br /> Owner/Operator Name <br /> Business Mailing Address, U b 4�A:: ApA: <br /> Citymako StateQR_Zip9<j LBus. Ph(3�f�(�- ( Alt. Ph. <br /> Odf h PG , 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 ohuta Cam' <br /> Date l <br /> 2. To-be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Kd j '1 I IOSCt� FA#_( <br /> Address PC e`f1eC <br /> i�r1 Bus. Phone �S�(�•-� 1CC <br /> s.� <br /> City P Zi ����� Owner/Operator � ! � YY�Ct y.-�'.�F,7 <br /> Check all appropriate services provided: <br /> Wastewater disposal 0 3-compartment sink Electrical hook-ups <br /> Solid waste disposal r Food preparation <br /> Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food <br /> g Potable water <br /> Store dry food/supplies g p g 1 Vehicle wash <br /> Overni ht parking E_, <br /> 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 own hall notify the EHD immediately. <br /> Signature .� <br /> Date_ j p�I <br /> 3. To be corn:leted 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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br /> t -2SDD271 <br />