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r <br /> SAN J O A Q U I N Environmental Health Department <br /> —COUNTY—— <br /> Greotness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 f_ic. Plate# <br /> Owner/Operator Name <br /> Business Mailing Address tL <br /> City Stateo:,& Zipq!5-�&2�Bus. Ph. 2,1 of 19 tj 4j)Alt. Ph. <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 ✓{ � +�.-� Date_�_/ 151— <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name rAttVbZjrFA# <br /> Address 14 YY-1 Bus. Phone <br /> City Zip GfC`�1-tom Owner/Operator � <br /> T1_ �� <br /> 96 Li <br /> Check all appropriate services provided: <br /> ❑ Wastewater disposal ❑ 3-compartment sink © Electrical hook-ups <br /> p Solid waste disposal ❑ Food preparation ❑ Toilet and handwashing <br /> ❑ Hot & Cold water for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies Jo Overnight parking ❑ Vehicle wash <br /> 1, 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 owne otify the EHD immediately. <br /> S'sgnature Date <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 /> 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 />