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Complete sections 1 and 2. If your commissary is located outside of San Joaquin- County also complete section 3. <br />Date <br />"7 U <br />Date <br /> DateREHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 (www.sjgov.org/ehd <br />f •• <br />1 <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ❖ Caterer <br />SAN JOAQUIN <br />COUNTY <br />?■ S Cl ~~ <br />Environmental Health Department <br />% <br />• 3 J £ O <br />5 m Z <br />2 s o <br />~ 2 Q <br />o m m > ™ CD > 2 <br />CM < £ <br />CM 2P <br />H W O <br />J <br />.5 <br />in <br />J <br /> m <br />1. To be completed by APPLICANT ' | <br />Business Name. ( CE. CA[>AP^Lie. Plate# 19 / Z? ($1 H — £|/ <br />Owner/OperatorName D 5 f)/\l <br />Business Mailing Address. F/ABO <br />City 5 C A Te> IA state Bus. M-P^jMt. Ph.l^f <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 />revocation and penalties. , <br />Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name T C K -0/ Q O FA# <br />Address Zr^r7//-)Z'/^?Q fl Bus. Phone <br />City <^5^^ Owfier/Operator <br />Check all appropriate services provided: <br /> Wastewater disposal 3-compartment Sink Electrical hook-ups <br />O Solid waste disposal O Food preparation iS^Toilet and handwashing <br />O Hot & Cold water for cleaning Store refrigerated food D Potable water <br />O Store dry food/supplies ~^O\0vemight parking O Vehicle wash <br />I,, 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 owner shall notify the EHD immediately. <br />Signature <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 />O) <br />6 <br />Is <br />£ >- <br />o F1 <br />CM