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KV192 690 <br /> CE.a 5ANUAQU � N p <br /> Environmental Health Department <br /> COU NTY- <br /> Gr-�ntriC: .5 fir•,- he.-.-. <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 /> 3 <br /> Business Name f Lic. Plate# ' b � tt' �1� fj <br /> Owner/Operator Name_ C-k— C <br /> Business Mailing Address <br /> City j � __State LA: Zip0jS3GL Bus. Ph. "ZAlt. Ph. <br /> 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 J aqui ty Environmental Health Department (EHD) requirements_ If the use of the <br /> commissary is discon ' ed, the per 't holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and a es. <br /> SignatJr Date Z "L <br /> 2. To be completed by COMMISSARY OWN/ER/OPERATOR <br /> Commissary Name lr l=A# <br /> Address Bus. Phone ( <br /> City L1JZ/ii Zip Owner/Operator 1�r� r� <br /> Check all appropriate services provided: <br /> Wastewater disposal lid 3-compartment sink 07 Electrical hook-ups <br /> Solid waste disposal ® Food preparation PrToilet and handwashing <br /> EF Hot & Cold water for cleaning ® Store refrigerated food Potable water <br /> pl Store dry food/supplies Overnight parking Vehicle wash <br /> _e hereby state that the information I have provided is current, true and <br /> correct to the best of my know , and meets the California Health &Safety Code requirements. If the food facility <br /> '006operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall otify the HD im diately. <br /> Signature <br /> Date �r <br /> 3. To be com leted by the E HEALTH 'udsdiction outside of San Joa uin 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 />