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r <br /> 4 SAN. J OAQ U I N Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <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 com leted by APPLICANT <br /> Business Name wck Q psi n Lic. Plate## � <br /> Owner/Operator Name4�r <br /> Business Mailing Address + <br /> City .State L i'' Zip_9 L4 0 10 Bus. Ph.� It. Ph Q S r <br /> 3 o� <br /> I, hereby state that the above: information is current,true and correct to <br /> the best 4 my k owled e anV agr a 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 T nA14 S,Ains Date <br /> 1.2. To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name � 11 FA# <br /> AddressM_ Bus. Phone 7Ogr <br /> CitZip Owner/Operator_ 0�kmiNX C ©CkL CA, <br /> Check all appropriate services provided: <br /> Wastewater disposal Lzr-3-�compartment sink " Electrical hook-ups <br /> LEf'Solid waste disposal f=ood preparation LA3--r"oilet and handwashing <br /> J,EIHot & Cold water for cleaning ore refrigerated food table water <br /> Stare dry foodlsuppliesOvernight parking �k7'Pe`fgicle wash <br /> l hereby state that the information [ 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 falls to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall no'f the EHD immediately. r <br /> Signature Date / r.�' �_.___� <br /> 3. To be completed by the ENV HEALTH jurisdiction otatside 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 I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> R2-ZW0223 <br />