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Environmental Health Department <br />Ci­ <br />commissary AGREEMENT <br />Mobile Food Facility < Caterer <br />SANJOAOUIN <br />------COUNTY------- <br />’,'eotne s grows hef\. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />KAVka p£2<50C)g)Z_ <br />Commissary Name <br />Address <br />City CZ) <br />Plate# H g(2.y <br />3-compartment sink <br />z <br />Q Food preparation <br />□Kstore refrigerated food <br /> Overnight parking <br />I -e x , hereby state that the information I have provided is current, true and <br />correct to thebesfof my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> <br />1. To be completed by APPLICANT | <br />Business Name_A4 If (- ffill <br />Owner/Operator Name-Sx»\Uc- I <br />Business Mailing Address /- 9\J <br />City?n44g<£»n ___ Statec/t Zip T Bus. Ph.Alt. Ph.J/p , <br />I, I f _, 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^^/ — _____________--------------------------------------------------------- <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />P pfa# <br /><x.f Bus. Phone 3 ~ ? 3 / <br />_ __________________Zip *7/# O f Owner/Operator d c <br />Check all appropriate services provided: \N\5Mc_v) <X / <br /> Electrical hook-ups <br />IH^Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br /> Wastewater disposal <br /> Solid waste disposal <br />Hot & Cold water for cleaning <br />□''store dry food/supplies <br />I, <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owner shall notify the EHD immediately.Suture Da^j/Z ?/_ --------- <br /> <br />[37To~becompleted~by the ENVHEALTH 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 EH^ / fhe status of their operating permit changes. <br />REHS Signature.. /J