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SAN JOAQUIN a <br /> Environmental Health Department <br /> -- -C O U N T Y----- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 9 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_ L_�"✓! �S ��a Lic. Plate# D D.S��Ncl�_ <br /> Owner/Operator Name b�coe- ) C,)o� <br /> Business Mailing Address l b 151 `)CLII Val 14 <br /> City v Is tate_(AAZi Bus. Ph._�pq_�r,<j]g5 Alt. Ph.-,;erq Sc -330� <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 /> LSigrevocation an n ties. ���_natu Date / y� <br /> 2. To be completed by COMMISSARY OW/ NER/OPERATOR <br /> Commissary Name 1 L FA# <br /> Address "<lr`l Bus. Phone <br /> City 4 "16 / Zi - !2S yC, Owner/operator "a A /11�41 <br /> 100, <br /> Check all appropriate services provided: <br /> Wastewater disposal /Ef3-compartment sink gElectrical hoofs-ups <br /> Solid waste disposal © Food preparation ,Toilet and handwashing <br /> Hot & Cold water for cleaning © Store refrigerated food fd Potable water <br /> 13 Store dry food/supplies XfOvernight parking Vehicle wash <br /> I, ���� hereby state that the information I have provided is current,true and <br /> correct to the 16e4 of my Vowledge,and meets the California Health&Safety Cade 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 owner shall noti tihe EHD 'mme ately. <br /> Signature L � Date, <br /> 3. To be com feted by the E ALTH 'urisdiction 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 />