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AN JUAQUIN Environmental Health Department <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 Nam Lic_ Plate# V ~] Z <br /> Owner/Operator Name <br /> Business Mailing Address <br /> City-� G16 AJ State-CA-Zip Ste - Bus. Ph.-20U 91-/-,.f ZJ Alt. Ph. <br /> I, iffe 11jay-\ 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 hol r m t notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties <br /> Signaturepate_ <br /> 2- To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name 1 VJ [ # <br /> Address-1-111 -DrWt] Bus. Phone - 2 <br /> City-210,K1d lj Zip 1S �OwnerlOperator {�-Q �rlrttf a <br /> Check all appropriate services provided: (� 0r7 <br /> Wastewater disposal /W 3-compartment sink Electrical hook-ups <br /> o Solid waste disposal Food preparation Toilet and handwashing <br /> Hot&Cold water for cleaning Store refrigerated food - Potable water <br /> -D Store dry food/supplies : Overnight parking Vehicle wash <br /> 1, V <br /> L'5� '`� , hereby state that the information I have provided is current, true and <br /> correcito the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fai o com the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary o h �,nofi the EMD immediately. <br /> Signature Date 2/ ) `2.61-jo <br /> 3. To4mricompleted 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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd__._ <br />