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SA N'd UAQ U IN Environmental Health Department <br /> COUNTY----- <br /> _ ; ,i i i ••. . (]r{n p� �l('r Q. <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 com ieted b fi.ARA`ill <br /> Business Name r C � Lic.Plate# 1/IV 3 Lf,,3-7. <br /> Owner/Operator Name o-Q <br /> Business Mailing Address c a C, o <br /> City State c,LZip�_�Ld fjBus. Ph. a 9AIt. Ph. <br /> I. , hereby state that the above information is current,true and correct to <br /> the best of my nowledge 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 /> Date Z ra <br /> Signature —�• <br /> C UiEE 'R- <br /> O �II S` �2. To::be corn is <br /> Commissary Name �,, tt FA# aQ <br /> Address (p ,I y ra '1 �3_ __Bus_ Phone - <br /> City rt.tA4 laclap Zip ��Owner/Operator `.�V.e� <br /> �_ <br /> Check all appropriate services provided: <br /> Wastewater disposal 10 3-compartment sink Electrical hook-ups <br /> Solid waste disposal ® Food preparation Toilet and handwashing <br /> ® Hot & Cold water for cleaning ® Store refrigerated food WPotable water <br /> ® Store dry food/supplies Overnight parking ay Vehicle wash <br /> j, , 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 own hall no ' e EHD immediately. <br /> re Date Z- <br /> Signatu 3. To b :com I ted!�b.'s tM;e.i M H r r s Ilc ariMautsi�de;o SSan,J•o :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 />