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SA N J OAQ U 1 N Environmental Health Department <br /> r11 <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 <br /> _L� - ( N ._` il E i_, J... Lic. Plate#_� �-- <br /> Owner/Operator Name <br /> Business Mailing Address S t,i(" <br /> city�� /�State p nZip ��7 Bus. Ph. ' _�nAlt. Ph..S I t <br /> �i A l ! 1 �_ 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 a penalties. rrj� <br /> Signature l� �;% r Date <br /> 2. To be com leted by COMMISSARY OWNEWPERATOR <br /> Commissary Name -1k <br /> �^, r r V [J �M SSA P1 <br /> Address i l l ] 's V f* j 1.. J� ST Bus, Phone_Lu C ?el )r' 5,�I <br /> City � �[_ �,( Zip Owner/Operator r u\ - <br /> Check all appropriate services provided.- <br /> Wastewater disposal 3-compartment sink 0 Electrical hook-ups <br /> " Solid waste disposal Food preparation totable <br /> oilet and handwashing <br /> Hot & Cold water for cleaning [3 Store refrigerated food water <br /> V Store dryfood/supplies [3 Overnight parking .Vehicle wash <br /> 1,_ �� r 1L N 'E 11 C--M jC' , 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 r shall notify t EHD immediately. C <br /> Signature f' '� ti'`L��-{.'N`'^� bate t I <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 />