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rqu,. <br /> S A N -J O AQ U I N Environmental Health Department <br /> PA kj& —COUNTY— <br /> Greatness grows here. <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 C\ Lie. Plate# 'A ' ley <br /> Owner/Operator Name {{ <br /> Business Mailing Address T <br /> City O State Zi Bus. PhlZ� :510 -'�W'Alt. Ph. <br /> l Use. b 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, U LiL ,�Y� v sM-c�� Date z z <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA# <br /> Address Bus. Phone IAJ 0Z Tf K 9- <br /> City Zip Owner/Operator <br /> Check all appropriate services provided: <br /> Wastewater disposal 3-compartment sink Electrical hook-ups <br /> Solid waste disposal 0 Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning O Store refrigerated food ,@l Potable water <br /> 0 Store dry food/supplies tp Overnight parking /— Vehicle wash <br /> I, „ hereby state that the information I have provided is current, true and <br /> correct to tNe 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 owner shall the HD im ea tely. <br /> Signature Ar— Date } <br /> 3. To be completed by the EN EALTH 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 /> VI C o 51"1 8` 2V <br />