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SA N J 0 A Q U I N Environmental Health Department <br /> C_ o u I'lll - <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 /> 1 . To be completed by APPLICANT <br /> Business Name CUPP lyJS Lic. Plate#3] <br /> Owner/Operator Name <br /> Business Mailing Address <br /> city_ k otiN State Zi Bus. Ph. p-Zo1A- Yj Ci q Alt. Ph. <br /> C1 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 /> l <br /> Signature_- Y1c `�_ _ Date�_ 1Z°�S r <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name PA## <br /> Address �, e.�1r�c���� c Bus. Phone `� - `7 <br /> City�� k �'� Zip c1`7 1S Owner/Operator 1 � k \J1Y16e� <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink Electrical hook-ups <br /> p Solid waste disposal 0 Food preparation Toilet and handwashing <br /> 13 Hot & Cold water for cleaning Store refrigerated food Potable water <br /> `X Store dry food/supplies Overnight parking Vehicle wash <br /> I, l� -YA6+' - �,11'1c11„ , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge nd meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comply with th conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediately. f <br /> Signature t ti ` bate / Ll A n � S <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.org/ehd <br />