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SAN JOAQUIN Environmental Health Department <br /> COUNTY-- <br /> Greelne,- grows here. Co <br /> py <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 9 and 2. 1f your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be completed by APPLICANT <br /> Business Name <br /> Plate#�`IS1 j�� <br /> Owner/Operator Name <br /> Business Mailing Address Ml (n S - <br /> CityrnQ( ���-O StateQ)pf Zipg JBus. PhC3Q ) lca-WMY.Alt. Ph. <br /> I,t2A- d 7-p(/,�2 G oCfi h et 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. ( 1 <br /> Signature olw Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary) `Name �`(-� f( �Q� S FA# n-1 OG q <br /> Address045 \1q aNchetr0 � Bus. Phone60< <br /> city Lo Aeano--, Zip 3(Dg Owner)Operator ' <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink E3 Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning Store refrigerated food Potable water <br /> Store dry food/supplies {� Overnight parking 0 Vehicle wash <br /> I, E(JOA-01 1 1 uy:ka�( 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 tails 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. l <br /> Signature Date 1 <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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br />