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SANA U Q U I N Environmental Health Department <br /> (1496�' —COUNTY— <br /> Greatneis grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility - Caterer <br /> Complete sections ] and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT Business Name A 4 9— Lie. Plate# V 2 Q <br /> Owner/Operator Name J <br /> Business Mailing Address Z_1 S P—I N &I HILL D i_ <br /> City Kzrb KState(A Zip6 Bus. P D -it 3� -Alt. Ph. <br /> 1, , 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 a penalti s, !i y� <br /> Signature Date t/ Z U 201 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L C <br /> Address S N S Bus. Phone_ (Z6G] ) le--i r- 51// <br /> city G Zip Owner/Operator J /9f A/F &! D6 <br /> Check all appropriate services provided: <br /> XWastewater disposal X 3-compartment sink 0 Electrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> Hot & Cold water for cleaning _: Store refrigerated food Potable water <br /> 4l re dry food/supplies Overnight parking Vehicle wash <br /> 1, UGC l� here <br /> by state that the information I have provided is current, true and <br /> correct t the besl of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commiss own r shalLnotifyHD imKnedi tely_ <br /> Signature Date Q <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa yin 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 />