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�3 <br /> SA NUJ 0 A Q U I N Environmental Health Department <br /> 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 kk <br /> Business Name J K UN I Lic. Plate# <br /> Owner/Operator Name 1V , N�LC + V E F 6 -K)D S A KC I N U (n A <br /> Business Mailing Address 0 \� I-I <br /> City L C State i ��Bus. Ph AA jhh. <br /> I, K�V G N e , 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 pena�V�r4 <br /> L <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryylName / C 4 I " <br /> Address; yet t'1 -�7� W 0 N S_� _Bus. Phone(:).U 1 � 1 Lo <br /> City S l V f�1 (1 nr�Zip Owner/Operator S !r—E NE _ E�D 6 <br /> \Check all appropriate services provided: <br /> "Wastewater disposal 3-compartment sink ❑ Electrical hook-ups <br /> Solid waste disposal ( Food preparation Toilet and handwashing <br /> of & Cold water for cleaning /p Store refrigerated food Potable water <br /> ❑ \St jre�d food/supplies p.❑ Overnight parking Vehicle wash <br /> �� ` hereby state that the information I have provided is current,true and <br /> correct to the best of ledge,and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to compl ith onditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ow r sh nNolg#EHD immediately. 4 <br /> Signature Date ITI 1 J <br /> 3. To corn leted 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.org/ehd <br />